Top Knife: Art and Craft in Trauma Surgery
238
Transcript of Top Knife: Art and Craft in Trauma Surgery
t'-
I||P IIEIIIT ART & GRA]I ||T IRAUTIIA SURGTRY
Asher Hirshberg MD&
Kenneth L. Mattox MD
Edited by Maty K. Allen
Illustrated by Scott Weldon
TOP KNIFE The Ad a C of l ofTrolmo slrgery
Cover design:
lJm Pub shing Ltd, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX, UK.Telr +44 (0)1952 510061i Fax: +44 (0)1952 510192E-ma i nikki@lfnrpubl ishing.com; Web s ie: www.i fmpubl ishing.com
Ediior: lMary K AllenDesign and ayout: Nikk Bramh l l
lllstrations by Scoti Weldon, Copyrighi O Bayor College of Med cine 2005
Copyight O January 2005, Asher H rshberg MD & Kenneth L Mattox MDRepr nted Apri 2005, October 2006
lsBN 1 903378 22 2
Apad ironr any fair dea ing for the purposes of research or private study,or crtcsrn or review, as permlt ted under the Copyright, Designs andPaients Acl 1988, this publcaton rnay not be reproduced, stored n aretneva sysiem or irarsmitted n any forrn or by any means, eectronic,digi ia l , mechanica, photocopyng, recording or othelwise, withol t theprior written permiss on of the publisher.
NOTICENe iher the authors, nor lhe pub isher, nor any other party who has beeninvoved in lhe preparai ion or publ icat ion of this work can acceptresponsibilty for any injury or damage to persons or property occasionedthrough ihe mp ementation ol any ideas or use of any product describedherein, Neiiher can they accepl any respons br iiy for errors, or.iss ons ormsrepresentatrons, howsoever caused,
Whilst every care is taken by the authors, the ed tors and the p!b isher toensure that all informatiof and data in ths book are as accurate aspossib e ai ihe time of going io press, il is recommended thai readers seekindependeni verJcat on of advice on drug or oihef product usage, surgicalracl_n qJes .r d c i rKa p.ocess6c pr or to r ' rei . Jsa.
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Contents
IntroductionWhat this Book is all About
SEcrloN I - Tools oF THE TRADE
Chapter l
r The 3-D Trauma Surgeon
Chapter 2
Stop That Bleeding!
i ct'upte' eI Youi Vascular Toolkit
Ii SEcrIoN II - THE ABDoMEN
Chapter 4
The Cxash Lapalotomy
Chapter 5
Fixing Tubes: The Hollow Organs
Chapter 6
The Injured Liver Ninja Masier
Chapter 7
The ' Take-outable" Solid Organs
53
TOP KNIFE The Ar1 & Croft of Troumo Suroerv
Chapter 8The Wounded Surgical Soul
Chapter 9Big Red & Big Blue: Abdominal Vascular Tmuma
SEcrroN III - THE CHESr
Chapter 10Dorble Jeopardy: Thoracoabdominal Injudes
Chaptff 11
The No-nonsense Trauma Thoracotomy
Chapter 12The Chesr Inside and Out
Chapter 13Thoracic Vascular Tmuma for the General Surgeon
SEcrIoN IV - THE NECK AND ExrREMrrrEs
Chapter 14The Neck: SaJad in Tiger Counhy
Chapter lSPeripheral Vascular Trauma Made Simpl€
Epilogue
The Joy of Trauma Suigery
pase
115
131
147
157
17L
181
't99
215
233
Contributors
Authors
Asher Hirshberg MD FACS, is Professor in the Depariment o{ Surgery'
iut" o.*n",*" college of N/edicine and Director of Emergency
i"'""rtu!' Srrg"ry "t
Xings County Hospiial Cenier in Bfooklyn' New York
Kenneth L. Manox N4D FACS, is Prolessor and Vice Chair of the Michael
i. o"ir*t Deparir.ent of surgery, Baylor college o{ Medicine' and
Cn[i "t
si"olin*t of Surgery at the Ben Taub General Hospltal'
lllustletot
Scott Weldon N,4A, is Supervisor Medical lllusirator in the Division o{
Cardiothoracic surgery of the Michael E DeBakey Department ol
Surgery, Baylor College of lvledicine, Houston' Texas'
Editot
Mary K. Allen BA, is Administrative Associate in ihe Michael E DeBakey
o"p"ri-"nt ot srrg.ry, Baylor College o{ N4edicine' and Administrator of
the Surgery Divisio; al ihe Ben Taub General Hospital' Houslon' Texas
To our residents -
past, present and future
Introduction
What this Book is all About
When you hatte to shoot - shoot' dofl't talk
- I1i Wallach (Tuco)
in: The Gaotl' the Bad and lhe U+l! ' 19136
Sooner or later, I haPPens'
You are a young aitending surgeon doing your first night on call at a
ur"u tt""t" ""*o
ol. " "rig"on
in a community hospltal facing a bad
traLr'ma case alone and wiihout backup Pefhaps you are a miliiafy surgeon
witn a forwarO or fietO Surgical Team sooner or later' you Jind yourseli
in tt e operating -om 1OR) ;ith a massively bleeding patieni rapidly dyrng
YoJ o|.icklv open ll^F beJy and blood gushes out LooD" o{ bowe are
"*^. ' ln i - ' ' " p.a
" f a"rr btood a'd c 'oLs Hect ic act iv iy sJrroJrds voL
as the aneslhesiology ieam struggEs ro open more lines while ihe
;;";",'"; ,.." rursJ" rapidlv oeprov 'nsrLmeri rrav5 YoL don\ need Io
,J* l , in" "n-"n
nrmbei, or r t te -ontor to leal i re I l "aI lhrs 's rhe
Moment. The skills that you have worked so hard to acquire are suddenly
pui to a very bruial test Can you meet the challenge?
These cases almost invafiably roll ihrough the emergency room (ER)
aoor" *h"n vo, t""t yo, are not at your best You are tired and tunning on
"rr l i i " . t u" i" t i "" Your sc,ub nu'"e is 'not very experienced' The
""""tf i"i.f"g
"t" afe doing lheir besi by pushing bolus after bolus of a
;;;;;;" ";"" iror'ooic-asenl rne crrcu'|arils nJ se d s'ppeared o'I
in" r" l r t * t""" t"" - ' "utes igoin searcr 'o 'your lavori le vascJlar clamo
Yes, this is deflnltely not a good iime, bul we can assure you' it never is
Tie audlble bleeding in tho belly, the controlled chaos around yo!' the
iii"n*n *a ,'ght" ii your head, and the clLreless assistant across the
TOP KNIFE The Ad & Croft of Troumo Surgery
operaling tab e are all pad of real-life trauma surgery. Oh, and by the way,have you noticed the anorexic chap in the black robe and hood, standingin the corner of the OR, holding this big scythe, and patienty wailirg foryou io make lusl one mistake? He, too, s an iniegral part of lraumasurgery.
Traurna surgery is an art ihat combines decision-making wth technicaand leadershlp skllls. The purpose of this book is io help you take a badlywounded patient to the OR, organ ze yourself and your team, do battlewith some vicious injuries, and come out wiih a live patieni and the bestpossible result. The siardard surgical atlas may show you whal to do wrthyouf hands bul not how to ihink, plan, and improvise. This book isdifferent. Here you wlllfind practrcal advice on how to use your head aswel as your hands when you are operat ng on a cfashing trauma patient.
Who should read this book? Afe you a resldeni or registrar in the sen oryears of slrgical traning? A general surgeon iniefested ln trauma? Afelow ln traurna and crrtcal care? lf you are, we wrote this book primarilywi lh you in m nd.
lf you are cufrently in lfaining, you must be aware oI ihe strong forcesdramai ical ly feducing your operat ive trauma experience. lJrbanpenetraiing irauma is dec ining, non'operatrve r.anagement is on the rise,and surgica train ng is undergoing a noisy revo uUon. Whle this bookcannot substitlte for gelting your clogs wet in a real OR, i can opt r.izeihe educationa value of every Aauma operation you do because you wii
lvlany operative encounters with bad inluries iake place in austerecifcumsiances, The rura surgeon doing an occasonal major yauma casealone, the miitary surgeon in the f eld, and ihe disasief relief ieam on ahumanitarian mission are examples of irauma surgery wilh extremelyI mited resources. Tackling a high-grade liver i.jury n a large irauma centeris bad enough. Do ng it n the only OR o{ a 20-bed hospila iakes tons ofcourage and resourceJu ness. li you afe ore of ihose surgeons, you areprobably more nteresied in slmple techncal solulions that work, raiherthan complex maneuvers that you wonii use aryway, Most operatveproblerns in trauma have more than one effeciive answer, and the trick ls
lntroduct lon w,o ih Boor B or "" . , E
lo tailor a simple, feasible soluiion to your speclfic circunrstances. In thisbook, we show you how to do jusi ihat.
Ths brings us to damage control, the biggesi buzzword in traumasurgery in the lasi decade. You rnay wonder why you don't see a chapteron damage control in the book. The answer rs simple. Damage control hasbecome such a centfal theme in trauma surgery thal it no longer makessense lo confine it to a single chapler Instead, detaied descriptions ofdamage control options and lechnlques are part oJ every chapter. Thinkingof ihis book as a comprehensive guide io damage control would noi be a
Why Top Knife? Top Gun is the popular name of the Naval FightersWeapons School. The r mission is io train the very besi fighter pilots forihe US Navy. We called our baok Tap Knife )n recognition of the manysimrlarities between trauma surgeons and frghter pilots: clear thifkingunder pressure, responding effectively lo rapidly changing stuatons, anda ong and arduous training process. Just like aerial combai, iralmasurgery is, f rst and foremost, a discipl ne. You cannot become a frghierpiot or trauma surgeon without a lot of hard work and willingness to face
The book begins and ends in lhe OR. lf you are looking for informationo n care of ihe njured patient beJore or after ihe ope ration, look e sewhe re.We also assume that yo! are famillar with general surgical princ p es andlec hn iq ues. lf yo u seek nstruclion on how to reseci and loin bowel or h owto do a standard vascular anastomosis, you w ll not find lt here. However,if you wish io learn how io do a no-nonsense crash laparoiomy, deal witha bleed ng Lung, or repair an injured popliteal ariefy, read on.
The f rst seciion of the book, Toals of the Trade, presents princlples ofirauma surgery that cll across injury types and afatomical areas. Ourfocls s not so much on how you should be sewing, but rather on how youshould be thinking and reactlng. These skills are rarey if ever talght lnsurgical irainlng. lf anyone ever showed yo! how io develop an alternativeplan whlle struggling wilh a bleeding subcavlan artery or to pay aiteniionto what the circulating nurse s do ng while you are manualy compress nga shattered liver, consider yourself very fortunaie. IVost surgical residenls
ToP KNIFE The Art & Croli of Troumo Surgery
and regislrars are expecled to just inluiiively piok up those skills
somewhere along ihe way Many never do'
The resi of the book is about trauma surgery as a conlact sport Here
*"'"i".* t"" n",r a o""lwith speci{ic injuries An impodant lheme is how
it',ino" "un
go "rong,
an aspect of trauma surgery seldom addressed in
:i,"L;J ;J; t;";.onaiize pitralls because recosnizins them is an
essential part of learning 10 operale
We acknowledge that the ari and craft o{ trauma surgery vary among
"";""";.';;"'il;",'prised lo find some differences in the approaches
r^, i . '^r^rrue orob'e-s between Ine auLnors Tl"e unoerly inq or lrLlplFs are
;":;;; il ""r-n'q,""
''" "o'"t'""s
d qere'.r' wl'ere such vaf:alio'rs
exlt, we have pointed them oLll No one size fits all'
In developing this book we had ihe good fortune to pariner wiih Scott
w"faon, "n'""ti"otain"tily
gifted young medical illustraior' The iranslatron
. i .*" t" , ,a"". "no.o*"ot*
nto qrapnrcar tot- 's alwavs a t ' (v
"""i."""t. ff'..1't to Scoii " taent and sLperb i,rlurtror' we we'e able lo
""fr""" tni" author_artist parinership as a single voice that seamlessly
interweaves text and an.
lvlarv AlFn, t\e most larenlpd Fdtor we l^ave ever worked wth did
,oln" ,'uoi"o ruro",y ot lne ipn ano mercrlessly bear h ilLo sl'aoe unt.l st'e
g";ii!", tiglt. Wih'*, t'er remarkable e{forts' this book would have been
much longer _ and considerably less readaEle'
Nikki Bramhlll, our publisher, was a lull padicipanl in this proieci {rom
rhe embrvolic sLages 10 lhe ii'rar prodLct She bougll 'nto our idea to
*r i t" ""
' j t t . " ; l : "" *""1 op"ral 've book or rraLma surgery and wo' led
;';;;" ;;"t step o{ the wav io make it happen Her infeciious
enihusiasm, h;rd work' and superb eye are evidenl on every page'
And now, ii s iime to stop talking - and start cutting
Chapter 1
The 3-D Trauma Surgeon
An erpett is a man who has made allpossible mistakes i a oery naftow fielil
- Neils Bohr
The flrst thing you notice on enlering lhe peritoneal cavily is bleedingfrom a arge nasty hole jn the right lobe of ihe llver Sirange y enough, youwere in exacty lhe same siiuaiion a week ago You don'i even have toglance at the monitor lo know the syslolic pressure is go ng to be 60Remembering last week's case, you rapidly pack ihe liver to stop thebeeding. Howeler, this i ime the injured vet cont inues io beed throughthe packs. lt was supposed to stop. lt did last week. What's wrong?Whai's different? You do a Pringle maneuver, but it doesn t help much-
The rietalllc voice of the anesthesiologist alerts you that the patreni's
systoic pressure ls now unobtainable. He s dying What s gong on?
What do you do now?
You rerialn surprisingly calm for a sutgica resident with ony three offour years of training. The reason is simple: you know exactly whai comesnexi. Soon the l ights n the Surgical VrtuaL Real i ty Labwil l be turned on
and ihe simllation wil pause. Using a revolving hoogram of lhe injuted
Liver and retrohepatic veins, your instructor wil explain what went wrong
and why. This dry clogs' approach to teachlng surgety ls rapidly
becoming a major part of surgical itaining. A simulator can helP yo! learn
10 operale, yel somerhrng l . r_dame' lra is aissi 'g
When you work on a simulator, operaie in a large animal lab, or work in
the OR with a good ieaching assistant, you learn ihe taclica dimension of
the operaiion. You learn to select from several technical optlons ard
execute your choice ln specific operative circumstances- You spend mosl
of your surgical training focused on operative tactcs in elective and
emergency procedures. Only when you begin operatlng on your own do
you become aware of the olher two dirnensions of every operation:sirategy and team leadershiP.
TOP KNIFE lhe Arl & Crofi ol lroumo Slrgerv
The shategic dimension
oJ an oPeraiion is ihe
broad considerat ion ol
goals, means, and
alternat ives. When Youoperale with a teachrng
assistant, Your teacher
usual ly handles ihe
strategic dimension lor
you. Whi le You are
absorbed in mobllizing the
spl€nlc t lexure, Yourieacher is already
weighing the options of a
rapid damage control
laparotomy against a time-
consumino definrtive repair. when you are working on your own' tne
",r.*i" "ait"""io" suddenly falls on your shouldefs You can no longer
io"r"""*"tr"iu"tv on d," fole; ln the colon, but must also considerthe 'Big
The ihird dimension of every operation ls team leadetship Being a
surqeon means making sure that ihe etforis o{ the OR ieam members are
coordinated and {ocused on ihe same goals You cannoi assume yoLlr
"irui t""t' lno*" tt'"t to do next lust because he or she is smari and
experienced. You must clearly communicale your pLan Similarly' the
anesthesiologist does not have extrasensory percepiion and cannot guess
your plan uniess you share i t - Mishandl ing ihe team dlmension dunng a
iuuma op"ration is one of the worsi mlstakes you can make
To operate effectively on wounded paiients' you musi train yourself to
be a 3-dimensional surgeon who consianily zooms in and out ot the
lactical, strategic, and team dirnensions' nronlioring Progress ano
reassessing options in each
I The 3 D Troumo slrgeon
Putting brain in gear before knife in motion
Srraleqic lnrnk;ng is essential even oe{ore yo!' make the 'ncslon
;;^d;: ;,'";"-pi",he brack no'e', oJ,sLrse'[ l;'fitiii,"J:.;"f:
::i:'",'::il:::,H""6J #,'-Jl-il:ii J"" r,s an obrisatorv,os;st'|c[1; ; ; ; : : ; ; ; ; ' ; r ' "" p. . ,ent is 'novFd oosir ioned ano preoa-ed but
nothing is done 10 stop inlernal bleedrng
l{ vou choose to spend most of the black hole iniewal at ihe scrub srnK'
*" i'"" ""i
* -*t;;an fingernalls, but when you enter the oR vou will
i; ;;;;;';;"""'tv oosiiioned Ll'e scrub nLrse prepo'ns Ihp wrong
i,"rl. ""1
,t'" on,"". "nort
in disartay You aray welr haverosl'ne battle
#;; ; ; ; ; ; " . . ; ro avoidt l ' ' |s srav wrth vour oat ienl unl" the'asl
o"i"ii'" .iit*t -a *e InP olack hore lor e'ective p'eoaratiols
ls the patient positioned properly? Does the OR ieam know which
"""]"1"" ;J ; ;;;;" ,ni *n''r''""t"'".' "ers
to deorov? Does rhe
;;;;"'. -"". need he p wilr^ rres? You ca'not address these
ir!ii'.#r",n ir''" ""',u "ink
Go ana s"rub onlv when vou are sure that
everyihing is set uP ano reaoy'
lf the patieni is in shock, don't waste.time on scrubbing Every second
"orni". j*, g" u go"n und gloves' grab a knife' and rapidly dive into the
chesi or abdomen.
Sterility is a luxury in severe hemorrhagic shock
The way You Posiiion the
patient and define the operatlve
lield are other indicatorc of }/oursirategic vision. Always Pfeparelof a worst_case scenario' In
iorso irauma, this typically
involves access lo both sides o{
the diaphragm and to the
grolns, Your worst_case
operative field extends from ihe
chin to above the knees'
IOP KNIFE lhe Art & Croli of Troumo Suroerv
between the posterior axtllary lines. Abduct both arms to allow theanesthesrology team full access to the upper extremities.
For isolated extremity trauma, include the entire niured extreriily in thefield to facilitate rnanipulation, and prepare an uniniured lower extremity {orsaphenous vein harvesting. For a neck exploration, pfepare ihe entirechest, since the uoDer mediastinum is a coniinuation of ihe neck.
Always prep for a worst-case scenario
ABC of tactical thinking
Traif yourself to ihink of every operatlon as a sequence of well-def nedsteps, but menrorizing the steps is not enough. You must ga n insight intothe procedure by earning the key maneuver and the piiJall in every step.
A key maneuver is the single most important technical act in anoperative step. The key maneuver in mobjlizing an injured spleen is incis ngthe splenorenal lgament and entering the correct plane beiwean ihespleen and the krdney. Often, a key maneuver is identlfying a gatekeeper,a siructure ihat serves as a guide to dissection or opens the cofrect iiss!eplane. The galekeeper ofthe carotid artery in the neck is the common faciavein. ldentfying and dviding it is the key maneuver. When mobi zing thehepatic flexure of the colon, the key maneuver is finding ihe plane betweenthe rlght side of the transverse colon and the duodenum.
A p/tfal/ is a major trap that awalts you in every operative step. Choos ngan incorrect ihoracoiomy incision or perfoming it ai ihe wfong inlercostalspace is a major pitfalj. Fail!re to obtain proximal control be{ore plunginginto a contained hemaioma is another classc trap,
Fam liarity with both the key r.aneuver and classic pitfall of everyoperat ve step s the d ifference between the trau ma p ro and th e wannabe.Knowing the key maneuvers and pitfalls ofa procedure allowsyou to pei{ormthe procedure lndependently and, with experience, teach lt io others.
Know the key maneuver and pitfall in every operative step
t rhe 3-D rro,rmo surseon I
A common tactical dilemma
"l:";f :;:1::ilil1',::ilT jlilH;"i""ji;ft ::::"H;FtiiK,f ily:Jt"f ?:r,ff Tiit"i,l,"?:Jl[:":'ff 1['ili::^-H]loJ"""i t-i
-t"" ut
"naini maybe it will wo* this time We can tell you
:il;:*[:lmig ii: :t'*"ll]; rl::: lxH"lff :;:lJ il"'Get used io lr"e ided that n,Ihe nt ::"",liJli"i"TJJ::1"::":::j
"*"'"-'";'ill'liJl"i,liiil;'i] Ll'l"""'" ;'| 'ai'| -re'rrect ve'|v no'l
" ."* i" ' ' , *n"" a maneLver ooesr t wori don t i€ke:t as a oersondl
failure. Pause and consider your optlons'
First, reconsidef the need {orthe
lailed ac1. ls it really necessary?
Does ihe bleeder require a sulure?
Perhaps it will stop wlth iemporary
pressure and Patience'
Another oPtion is to retreat and
gei help lt You are iortunate
enough to have backup' use lI'
Someone more experienced oiten
has a better chance of solving the
problem, Recognizing the need lor
irelp and asking for ii (whether you
are a resident or seasoned trauma
surgeon), is a sign of good
ludgmenl
what ir you are compreierv ":1111:Y: *i"J,?:;J;til;,:::lilT:l::'[f]''T#'.""''fl5'$li]:"i"."iJ::1ff l'"" "st come up wirh oneihai will.
,'"Hl"i::"i:Xff ,i:ili, tii,'i5;Jlliiiill ll'iil"Jff T:['""5i
getreaf
.f"c aot.
TOP KNIFE The Ari a Crof i of Troumo Surgery
envrronment: lletter exposure, an improved angle, a longer needle drrver,a bigger needle, or a better asslstant. Such a taciical change improvesyour chance to succeed in ihe next aitempi. tdentjcat repetition of anunsuccessful iechnical act is a nristake because ii almost always fails. Thrsis lhe very deflnition of flailing and exactly whai you must avoid.
Remember these four options for dealing wlth technical failure. They areyour iickets oui offrustraUng and dangerous situations. Effectjve surqeofsdon I take lech'r ,cat ta lLre as a persora .nsrt t . Tt-ey .ap dly reasse;s thesiluation and come up with an alternative solltion.
Avoid f lai l ing; learn to dealwith technicalfai lufe
a
Tactical flexibility
Regafdless ofyour experience, you willfi/rd yourseif in sttuatrons whereyour inventory of slandard techniques simply will not solve the problem,forcing you to figure out a new solution. Tactlcal flexibility js the ability todevise new solutions to unusual operative situations. lt is an acquired sklllthat you can develop by learning to think outside ihe box.
When facing an unfamil iar problenr, ask yourselJ the fol lowing
Have lencouniered a srmi lar st tuat ion in another context? ln electvesurgery? In another injured organ or anatomical region?Can I modify or adapi a standard technique to the situation?How about solving part of the problem?Can I leave the prob em unsolved {or a while and come back later?Whai is lhe mininral accepiable option to deatwtth the probtem? Witldraining the niury (and creaiing a conifolled fisru a) be good enough?Can I hgate the vessel lnstead of repairifg it?
In a complex situation, always strlve to simpllfy the problem. Assess iheiniufres and decide which injured organs must be fixed and which can berapidly removed (or fesected) and, thus, etiminaied from the equation.
aaaa
Make your reconstructions as simple as
yoLr rnake, the better. ln trauma surgery'
solulions often backfire on You
1 The 3-D Troumo sureeon I
possible. The fewer suture lrnes
simple solutions worKi compLex
The key stratedc decision
Every trauma operation follows a generic sequence of reproducible
o"-0". i", g;t """"*,o
the injured cavity' control bleeding and spillage
;#; t;;;;;,y '"""u,.", "ni
then explore ihe cavitv to define the
K" \..t11- a//
" "*' +\9 ot;*a
//,// " t! \/ 7 / F ' i ' \ !Acc€$ and TempoEry Bleedlng ErploEtionExpo.ur€ conlrol
Now voJ lace tl'e kev strategic oecison ol tl'e ope-aiion ll'e cro'ce
o"*""" a"ti'ni"" 'epai' ana Ja-ag" control Dernd^e rcpai mears
Lection or reparr of the injured organs and {omal closure oJ ihe cavity''Fti',i
""ri,[,."i.",^pij bail out u"ing temporary control measures and
l-""i"* U""rr" ol Ihe cav;ty. will' a planned relur' 'ater under mo'F
,,;;;;"'";;"";""-. vo, ju"r -at'" it'
" d""'s'on vFrv earv Don\ { 1d
yoursel{ abruptly bailing out in mid'operation becauseihe pai|enl rs crasnlng
How do You choose the operative profile? Consider fouf key Jaciors:
iniurv oaiter;, rauma br.rrden, physiology' and system
a What is ihe injury Pattern?For example, in a high-grade liver inlury'
Simplity complex tactical situations
d h
once you recognize the need
a
a
TOP KNIFE ]he Ad & Croit of Troumo Surgery
for packng, damage control is your only choice. Simiar ly, thecombination of a major abdominal vascuJar injury and intesiinalperforalions usually requires a rap d bail out, because by the time youfinish dealing with the injured iliac artery, the patient wil be n nocondition to undergo bowel resection and anasiomosis,What is the paiient's overall ifauma burden?Look nto the njured bellyt how many organs do you need to lix? Howr.uch work is involved? What aboutthe chest? Any press ng concernsin the Imbs? The pateft may need two hours of reconstructive work,blt with a head injury and a diaied righi p!p I, you don'i have the iime.The overal trauma burde. oi a pailent s a combination of the njuries,iheir relative urgency, and the amount of work (and time) required todeal wiih ihem. Investing precious irme in definitive repair of nonl/feihreaiening abdominal injuries n the presence oJ big uncenainties inihe head, chesi, or neck is a very bad move.Whai is the patient s physiology?The numbers you see on ihe anesthesiologist s monitor are noi veryhe piul because you are not interested in a snapshol of ihe patient'sblood pressure or oxygen saturation. You are ifierested in ihephysiolog calimpact of ihe njury overtime. The instanianeous numbersyou see on the monitof mean very ittLe. lvlore on th s n ihe next seciion.What system and clrcumstances are in play?Are you an experienced trauma surgeon working n a trauma centeror a generalsurgeon operaiing in a tent in Africa? How mlch biooddo you have? How good is your anesthesiologist? You musiincorporate ihese considerations into your decision. Damage conifolis the 'greai eq!a izer" o{ tfauma surgery, alow ng you to compensaiefor nexperence and lmited resources.
Damage control is the great equalizer of trauma surgery
The decision to bail out and the physiological envelope
ll the patieri s cLrnent blood pressure is 120/70 wiih good oxygensaturation, the anesthesiologist wil often tell you the patieni is stable.What if this patlent was n shock for an hour before ihe operation and lostan entire blood volume before you gained conirol? Are you going to do a
a
r The 3-D rroumo surseon n
bowel resection and anastomosis? lf you answer' 'Yes" please say you
:rinrijffi :r";'; * :i ;* *:6116';F#l,1i#lll,J""''-,"?l;,1':#T" "# "T ;'"""," m;ss ve r'|J'o
:r"L",":*:*1,*n::i:'::::"ffi i,Bff iJil'iJ""":*iii:lil:Ir*ri"il" ont"i""n'""1 insult, not the numbers on the monitof screen'
should guide Your decision
ln the damage control
l i teraiure thefe is much
discussion o{ the ' lethal
tr iad" of hYPothermia,
coagulopath)/, and acrdosrs
These three Ph]/siologicalderangements mafk the
boundaries of the Patlenl s
physiological envelope'
beyond which there is
irreversibLe shock and
death. A core temPeralure
below 32'C during a
trauma laparotomy is
considered universallY latal
Unfor iunately, in real- l i ie
;;;;;;,0;;t ihe leihal t ad does noi help vou much lf vou have a
;;;"i;";i srasp of the situation' votr will bail out well before the
p"o"nt'" pf'V"i"f.gi."f envelope is anywhere near the point ol no relum
Beino {orcei out o{ the chest by a core temperaiure o{ 33"C' a pH of 6 9'
""J I J"**"," anesthesiologist is not a sign of good judgmenl You
should have been out of that chest long ago
Don't use the lethaltriad as a guide to bailing out
TOP KNIFE The Ad & Crofl of Troumo SL,rgery
Instead of the lethal triadj re y on a seres of subile perceptua cues torndicaie a developing hostie physlology.
Intraoperative Cues of Hostile Physiology
Edema of the bowel nrucosaL/idgut distensionDusky serosal sudacesTissues cold io the touchNon compliant swollen abdominal walJD ffuse oozing from surgical incisions
Edema and distension of the smal l bow€ are relatrvey early warningsigns, whereas diffuse oozing from the operaiive incision s a late one.
Experenced irauma surgeons decide on damage controlwth n minl tesof eniering the abdomen and sometimes even before making ihe incisionlThey often recognze a paltern of iijury and physology thai, in theirexperience, amost always eads to darnage contro. N4ore on this n ihechapter on thoracoabdominal injuries.
How well does youl solution fail?
lfyou choose an operative prof le of definitive repair, there s usualymore than ofe repair option. The iypica dilenrma s beiween a shorter,simpler repair and a complex and more tme-consurning reconsiructon,
When choosing between several technical solutions, consider not onlyhowwel a padicu ar optiof works but, more importaftly, how well ii fals.Whal w ll happen if the anasiomosis leaks? Whai f the repa red spleenbegins to bleed again?
There is a world of difierence between a leakrng colonic suture ine anda fa led pancreaticojejunoslomy. The former is eas ly salvaged by proximadrverson; ihe lat ter is a much more orninous compl icaion, not easy iomanage. Can your patient tolerate a failure? A young healthy patient wlth
I The 3 D Trourno Slrgeon
an rsolated bowel rniLlry will suruve a
surure line A criiicallv injured patieni lnleak {rom a gasiroiniestinal (Gl)
mulii-ofgan failure will not'
Choose a definitive repair option that fails well
Team leadershiP
Picture yourself going headlo'head wiih an inaccessible hole in an iliac
"" ' " ""* '4"*", i t lJ peru:" Your oal ier ' s n ororouno sl 'ock and
blFeoinq aLd o'y. YoLr ieam has ore c rcu alng lurse DepFnd'ng o'r yoJr
n" ' , i , "0"""t . ,a" . rr-" * i l e i lh€r go nJ'r , i "g lor your pe'solal ized needle
ariuer ttrat ttas ihe ideal angle {or your next 2_3 bites' bring a Fogarty
iattoon catleter itrat can free yourfinger from compressing ihe bleeder' or
; ; , ; - ; - ' a-.olr€1s{usio- 'devce whcn is more impolant? ore
lir""t"tor, ,r'r"" ".."niiul
p:eces o equrp'ne,rI needeo ar t'r. same Iime _
it s your call
Constantly re_evaluate your priorities and your team' adapt to the
situation, and make comprornises' lt is often said thal excellent surgeons
i""" .oo*" wiih a knife and fork' ls the special clamp you requested
real lv essent ia? Ca'r you gel by wirn a 'ess opi imar bJr _nedralely
""lii"oi" "r".p" wn"t *ill vor neeo ir live mi'utes? lr +en mi,lL'es?
The kev to a smooth and welfcoordinated operalion is to siay ahead ol
t fe oam"les a rut" , t t "
scrub nurse should be at least one step ahead ol
ii" ""0"*i"" at any given mor'ent When you are exposing an lnjured
ue""eL, the ".rrb
nu."" musi already have clamps for pfoximal and disial
"oni.i. ff't"
"it"ufutlng nurse must be at least lwo steps ahead' riaking
"rr" if1" ,n" Fogady Lalloon calheter and the suiures you will need fot
*r"*""a.t "ia
,"pul, "r"
ready You, ihe surgeon' must be at least
three steps ;head, considering your reconstrLrctive options Just as in
ci"ss, tne bette, play"r you are, the further ahead of the operation you wrl!
stay.
Stay well ahead of the operation
IOP KNItE The Art & Crolt of Troumo Surgery
Maintain a continuous dialogue with the anesihesiology ieam across ihedrape they call 'ihe biood-brain bafrier," and provide them wiih theiffornration ihey need to stay ahead of the operation. Remember that youare working in one of several potentially injured caviiies, and often the onlyclue that something is amiss in another visceral compartment will beobvious only to the anesthesio ogist. Train yourselJ io listen to the monitorwhi le you are working and to pick up any unusual moves or noises on theother side of the blood-brain barrier. Sometrmes the nrost criiical part ofthe operation is tak ng p ace there, oulside your field of vision. While youcannoi see tj you can train yoLrrcelf to leel ii.
Frequent changes in the operaiive plan are a salient feature of surgeryfor trauma, and it is your responsibility to make sure ihat members of iheOR team aro noi left behlnd when the operative plan suddenly changes-Avoid surprises by sharing your tactical and strategic decisions with them.Consider, Jor example, the simple act of transporting a damage controlpatient to the surgical irienslve care unit (SICU). lf the team is unaware ofyour intention to bail out well in advance, you will find yourself in theridiculols situation of having just performed a lightening-speed damagecontfol laparotomy, only to spend ar almost equal amounl of time waiiing
Unike chess, trauma surgery is a dynamrc process. lr chess, thepleces are just silt ng there, waiting for you lo make a move. A traumaoperation moves forward relentlessly whetheryou like it or not, confiontingyou with rapid y changing situations. lf you are an effeciive 3-D surgeon,your handling of the tactical, sirateglc, and ieamwork dimensionstranslates into a smooih and etfective procedure.
T H E K E Y P O I N T S
Sterilily is a luxury in severe hemorrhagic shock.
Always prep for a worst-case scenario.
Know the key rnafeuver and piifall in every operative siep.)
I
) Avoid flailing; learn to deal with technical failure
) SimPlify comPlex tactical situations'
> Damag€ control is the "great equ€lizer" of fauma surgery
) Don't use the "lethal triad' qs a guide to bailing out'
> Choose a definitive repair option that'fails well'
) Stay well ahead of the operalion
r The 3-D Trcumo strrgeon I
[ ,o, *",rr rn. on & crofl of Trourno )urgery
Chapter 2
Stop That Bleeding!
Whenezet yot encotnter fiassioe bleeding' the
first thixgio temembet is: it's not y91!r blood
Raphael Adar, MD, FACS
In 1989, while discussing a paper on liver injuries' Dr' Francis Carter
Nance ol New Orleans made the following comment:
"l wauld like to offer Nance's ctassification of injuries' which has the
advantaoe of not needing to laok at the oryan injured' but at the resident
who is ;here at the operating table lf he ar she looks at lhe waund and
vawns and turns it o;er b the juniar resident, then it is going to do well
it i" o"Aq n hate a hgh su^ival rat1 tt he look> at the injLtrr and
,"ii"l,"r.l.*"t ,""n, ,n;l the 'esidert will have to da some suturing and
reallv help the patient, and the moiatly rate witl not be high' and he ar she
wil'look gooi during the notuidity'nonatity conference lf the tesident
sweats...ihat means that he ar she wilt da a lot of sewing' will encaunter
a coiptication, ara witl nave ta defend hinsetf or herself at the nohiditv'-'rf,i"iti,
"or"nn"" "ro probabtv receive a tat at heat And il th. residenl
".--r"rt'" ,na r"^" for the anendng toLt Ana' hat the pahent wi do
(A'n Surg 1990; 211: 673-674)
When vou are operating on a bleeding paiient' it all comes down io a
simole question: can you stop the bleedlng be{ore the patient runs oul or
iilJai il'" r."v ,o "r"""ss
is noi how votr handle a vascular clanrp' but'
ralhef. how vou handle yoursolf and your ieam Bleeding contfoL Ls not
"Oorr'."oJrnn some cool moves lt is ihe ability to rapidly select
appropriate he;ostaiic options and deploy ihem one after the oiher In a
discipiined, eflective fashion Here s how lo do it
TOP KNIfE The Ari & Croit of Troumo Surgery
Choosing a hemostatic option
Don t feflexively jump on a bleeding vesselwith the {irsi available ctamp.Instead, train yourselfto think o{ every bLeeding siiuation as a problem thatrequires an effective solution. There is always more than one alternative.Your job ls to come up wiih a solution ihat will work for the specificsiluation in front of you. Therefore, the first rule of bleeding contro salways seJect the simplest, most expedieni hemostatic optjon.
Begin with the simplest hemostatic option
Whal are your opiions? lf you have some surgical experience, your listmusi begin with 'do nolhing.' This is often an exce lent choice becauserely ng on ntrinsic hemosiasis works surprsingly well for certain iypes ofminor hemorrhage, like superlicial oozing from solid organs. Your list ofoptions probably goes on io electrocautery and ligation and ihen graduallyescalates through the use of henrostatic sutures, packrng, batloonta..ponade, and all lhe way up to a formal vascular fepair. You will notinsert a hemostatjc sulure unless simpler means have either failed or areinappropraie. Therefofe, the second undeflying principle is a graded
Bleeding control is a graded response
lf the first soution you chose didn'l work, gradually escalate yourefforts. An experienced surgeon rapidly zoor.s in on the 2-3 besthernostatic optons for a given situation. This principle of a gradedresponse has an important corollary: while you deploy a hemosiaticsoluiion, ihnk ahead and prepare an alternaiive in case your selectediechnique doesf't work. Why is this importanl?
The more complex youf next hemostatic solulion, the more time rt takesto prepafe. When faced with massive bleedirg from an inaccessible siie,preparing an alternative becomes crucial. l{ your chosen solution doesn'twork and you are not ready with an immediate alternative, you are up the
2 siop Thot BLeedinsl H
creek in search or a paddre,Havins-a hemo::1h":iTli,',^1ii i;i;t;:accideni. lt requires careful plannlng ano
iO"iO*"", "t,""*
V." *ill need and where they can be iound'
Temporary and definitive control
Temoora'v control is ,il.e plugg ng a ho e ir a reaky buckel wr|l- your
t"" . , . "6"t ' i i , ' "" conitol rs l ' ing tne oLrclei ln rassve breedirg
,eiolr , rv.onrtot 's r t*ays .ne r ' r5l s iPp becarse r al lows vou io assess
ii" "ituutlon "nO
a"ptoy in appropriate definilive hemostatic measure'
Temoorary solutions musl be quick' eifective' and atraumatic ln certain
r '^ta"" "1"*"
ft *len tne bleeder is eiil er iraccess'b e or oifl cL'll to
.1"""r . ""r . I" .06"",v
cont 'o ' l raneuver (sJch €s pacl ' rng or bar loon
;;;;;":;t ,n;y ;., " "',t
to be tne der'n'|L ve -Fdsur€ becduse thFre s no
oerter opt 'on. l { vo.r Le'npo'ar ' ly Packed a oadly injJ ed l ivera,rdi t s 'opoed
bleedirq, don\ ie-ove rl'e Pachs You ,lav€ acl'reved etteclrve lFmoslaqrs
- good enough Move on
Be ready with an altemative hemostatic optbn
ObtainingtempolarY contlol
Manual of digital Pressureis an excellent first chorce.
Conirol bleeding from a
cardiac laceraiion wilh Your{ingef. Pinch a mesenteric
bleeder beiween lhumb ano
foref inger. Compress a
bleeding iniernal jugular vein
with your f inger ' lnseri a
finger into a hosing gforn
TOP KNIFE The Ad & Crofl of Trourno Surgery
Have your assistantcompress an Injuredliver beiween the palmsof boih hands. Usingyour hands is quick,instirctive, completelyairaumatic, and very
A classic enor of the novice is to grab a clamp and try to blindly applyit in a pool of blood. This nevef works. Vascular clamps are effective whenthe larget vessel has been dissected out and isolated, not when ii hasretracied inio the tissue or is barely visible. Blind clamping is a sign ofpanrc. You will not only farlio achieve control, but also will end up with aniatrogenic injury Wild clamping o{ the descending thoracic aoira cafeasily result in an av!lsed iniercostal artery. A clamp apptied hastily to thesupracelrac aorta may perfofate the esophagus. Blind clamping of a limbartery in a pool of blood wil crush the adiacent nerve or iniure theneighboring ve n. Un ess you are !nusually talented, you cannot perforatelhe esophagus or crush the median nerye with your f nger
The finger is mightier than the clamp
Temporary packing is a good option for diffusely bleeding surfaces orcaviies. lt also frees your hands. However, packing will not control malorarierial hemorrhage.
Pedicle control is anoiher opiion. Does the lnjured organ have animmediately accessible vascular pedicle? The spleen, kidney and lung do,as does the bowel. One of the iwo vascular ped cles of the lver is easiyaccessible and can be rapidly pinched between thumb and forefinger orclamped with a non-crushing clamp, the famous Pringle maneuver.Similarly, if you mobi|ze ihe sp een or kidney you can rapidly conirol thepedicle with your fingers or a clamp. Twisting the lung upon itself rs asimple and effective technique for hemorrhage control, asyou wi/ldiscoverlater (Chapier 11).
2 stop rhot Breecrine n
Temporary conirol buys you time You can relax for iust a momenl' ger
,f'""i,Jufu,io" o".f i*o your compressing hand' s!rvey the situation and
decide how io Proceed
Small problem or BIG TROUBLE?
Now thar vo- have galreo tempo-ary conl 'o 'and bood ' no longer
*r,"" " , i "*r
you, olo"r" , .u" ' rFld you h've -eached thF kev iaclrcal
il"i"'"'" ," i":.i.*" conrrol: tn" d st ncliol between d smalr prob'e'n
and BIG TROUBLE
A small problem is bleeding you can control using a direct hemostatic
nl"n*""t ' f i t " c lamping, sutr 'Lr ing' or reseci ing the injured ofgan
H.morrhoqe fror an rr iJ-ed sp'epn rs a smal ' problem aq is a p' t roh"ra
;, ' , ; , r"" ; ; ;" . " ' "
; q 'ade ' iver rr i ' r ry ' Tne sred naror 'v ol breedins
"ir,,"",lon" you encounter during a trauma operation belong In thls
category.
BIG TROUBLE is an entrrely di f ferent kenle of f ish-a complex or
inaccessibLe injury ihat poses a clear and immediate danger to your
p"'""* lii". e'n,nnn*de liver injurv is the prototvpe o{ BIG TRoUBLE
iteeaing from an iliac vein or a posterior intercostal ariery deep in the
lower chest are other examPles
The dlstinction behveen a small problem and BIG TROUBLE hinges on
" "".Ui*rt" of the bleeding rate and the accessibiliiy o{ the bleeder'
;;;", ;" peripheral mesenteric vessels can bleed more than a
I""t"t.i- n".""rn" in the base ol the mesentery' Yei peripheral
.""""t"ti. O""a-" *" a small problem because they are accessible and
"; i; d;i;,h. Bleedins fiom the rooi oi the mesenterv is BIG
in6ugrr u"""r"" l t impl ies th€ need {or vascular reparr oi an
inaccessible superior mesenieric vessel
olt"r.i* it th," lt""aing organ has a vascular pedicle
TOP KNIfE The Arl 6 Croft of Troumo SLrrgery
The upper abdominal aorta s difficult to access and control; therefore,a midl ine supramesocolc her.aioma is atways Btc TROUBLE,regardless of how much rt has bled. Free hemofrhage fronj theretrohepaiic veins ls BIG TROUBLE, not onty because it is fast andfur ious, but also because you cannot get to i i . Accessibihiy depends onthe pat ient 's posi i ion and on your incision. For example, an injury to theposterior thoracic wall may be inaccessible from an anterolateralthoracotomy incson, but easy to reach through a posteroaieralihoracoiomy,
Learn to distinguish between a small problem and BIG TROUBLE
Small problems and BIG TROUBLE fequire di f ferent mindsets anddifferent operative approaches. You can tackle a small problem directly byimmediaieLy deploying appropriate hemosiatic solutions until the bleed ngstops. One of those soluiions s likely to work, and the b ood loss wi| bel imited.
lf you j!mp if and go head-to,head wlih Blc TROUBLE, you tose. Thepatient is profoundly hypotensive from niassive blood loss. The OR ieamhas no idea how bad the stuation rs or how you plan io deal wih it.Exposufe is bad. The 10-12 units of blood the patient will need afe st tt nihe bLood bank. The vascular insifuments you will need are siored outsidethe OR. In other words, the odds are overwhelmingly siacked agalnst youand your patient even before you begin. A frontal aitack (as you did for asmal l problem), wi l l be l ike a bungee jump wthout a cord. Unless you dosomeihing to even the odds, you're f nished before you siari. So, what todo? The answer may surpfse you.
2 stop Ihai BleedinsL I
Update
Once you havF gained te-po arv co' Irol_ STOP' Res:st lne templal ion
," I-.""a1"*,, p,"J""" to de 'nrLrve 'ontror' Ins'ead orgarrTe ard oprrm:ze
your atiackl
. l"l::T,:",",."jf il:x'.:JxilJ,",.'fi"1'J"':;ii::J::,:fi:':".,:l:X1least 8_10 units of blood and a raprd lnruser'
O Ger an a.rovans us;on dev:ce p i-ed and wo'(lng
; :li:;*".::;"n,::il fl:"';:11",":ili:1"11:'#;;:i:ll. "J*m.J1';;x;14 l+i!ill:.#.'":,,# 5l ;: x:
addit ional equipmeni l ike a Foley or fol
. X"'S::"'H"#;;ffi:Jil!:f"""; '"".' can thev handre the rorreF-
1""",* l.lJ" ai""at should vou set additional f"uFfi"""ning u
""r{-'',:,:f ;::ii::ff iJ'il'"'#J"t'1i11",,*"""*"While all ihese preparations are moving forward' don't fiddle with your
,".o"i"tt """i,J
L"""" the packs alone' maintain manual pressurer ano
don t move any clamps
Don't fiddle - be a rocx
TOP KNIfE The Art 8 Croft of Troumo Surgery
Siand calmly and patientJy wjih your hand on the bteeder and wait unrilthe ieam is ready, the patient has been resuscitated, and ihe appropriaiernstruments and help are in the field. you have carefujly set up youf attack;now wage your battle under favorable circumstances.
When_dealing wrth Btc TROUBLE, resist the temptation io keep onmoving. The drama of exsangLrinating hemorfage rs s(jch rhai the ieama\pecls you lo 'do sometning. stopo;ng lhe ooeraion in mid-ar-,s l .e lasrIrrrg they e,oect. Neve.tretess. Instst on co_p,erng at prepa.arons evenif it takes a considerable amount of time. We have occasionaily stooa witiour hand on the bleeder for 15 minutes or more whi le the OR ieamco-'rolelFd p.eparat,ons fo, baflte ard -he oat.elt was being resrscrtatFd.-are1uF. prepa-at,on ard olann ng give yoJ a huge tacl ica. eova'r ldgF a'rodramanca ty improve your palent s chances,
We cannot overemphasize how criticat it is io distingutsh between asmall problem and Btc TROUBLE_ This may we be the most imporiantdecisiof of the eniire operation. ll is often a sublectrve decision thatoepends on your experience and confidence. A situaiion that a surgeonwith limited trauma experiefce considers BIG TROUBLE may turn o"ut tobe a small problem for an experienced co eague. Nevertheless, if yourimpress/on is thal ihe situation merils an organrzeo attack, you wiil nevergo w-o19 oy dporoacri"g r t ar Btc TROUBLE.
Selected hemostatic techniques
Pdckitlg 701
Packing is one oJ the most underrated and badty taught iechniques inIlula
su]Sery. lt is also one of your best weapons fof deating wiih BtGTROUBLE. Surgeons tend to think of packing as such an intuitive skill thatthey rarely bother to teach it properly. After all, you don,t have to be asurgjcal genius to stuff some pieces of cjoth afound a bleeding liver _wrongl
Always err on the side of caution
2 stop lhot Bleedinsl n
The fitst rule of packing is io do ii early.since packing relies on'clot
"rril,""l',i "* ",i,, l" Jtfective if done when the patient can siill rorm
n""J"[i'" t"lnan "" "
last resort' when the patient is coagulopathic and
oozing fronr everywhere, is futile
There are two main ways io pack Packing fron without is c]eaiiq a
sandwich. Packing from lthin is filling a cavity
Pack from withoui bY
placing laPatotomy Padsoutside the rnlured
organ to reaPProximatedisrupi€d iissue Planes.To achieve effective
hemostasis You must
create lwo opposingpressure vectors that
compress the injured
iissue between ihem;
otherwise, Yout Packrngwlll not wofk. EffeciNepacking is a sandMch,
Tn.e recn'1ique " mosl olier used ;n the :nrured livet A good sandw cn
arouno t l 'e l ive- cons sts o' iwo rayers o' laParoto-y oads {aoove ano
U"to* o, "nt"riot "na
posierior), apptoximaiing the disrupled tissue planes
O"*""" *". t** ,Vefs are suppoded' in lurn' by ihe abdominal wall'
i* a:uprlrug,n or by adracent aodom:nar organs s'icl- as ihe slomach or
l^roe bowej. You cannot c'eate a good sanow cn by Laigrrg two p'pces
ni"t,""o ,n n-,0."i-. Vorr "andwich
.nust -akc mechanical sprsF
)
TOP XNIfE lhe Ari I Croft of Trourro Surgery
Packirg from wihin isstuffing a crevice or anacilvely bleedjng cavity withabsorptrve gauze. The filling,consisting of an unfoldedgauze rol , is push ngouiward against ihe walls ofthe injured parenchyma.
Your packing techniquemust be iai lored to theshape of the injury. lfdeal ing with a largebleedlng surface or mu tipleinjur ies to a sol id organ,
pack fforn without. When packing a beeding crevrce, like ihe deepperineal wound of an open pelvic fracture, pack from within. ln severe liverinjuries, such as a siellate fractufe of the dome oJ the rjght lobe, you willotten find yourself !sing a combination of both techniques.
Packing from without or within works in oDDosite direction
The thifd rule of packing is io avo d overpacking. While construct ngyour sandwich around the inlufed liver, pay special atteniion io thepaiieni's blood pressure. lf it suddenly plur.mets and the anesihes otogisishows signs of distfess, your packs may be compressing ihe inferior venacava (lVC) and diminishing venous return to the heart. Caref| y remove afew packs and reassess.
Too much packing is bad
The fourth (and ast) rule of effeciive packing is to be paranoid. Therers aways the danger that your packs willfot work, bui it usLta ly takes timeto find out. Laparotomy pads have an amazing absorptive capactty, and ihepatient may wel/ continue to bleed lnderneath them. lf the patiefi sphysiology allows, spend at least a few minutes doing something else, and
2 srop rhoi Bleed.q n
t:T;:'il";ift i"J::"::,,,1"if ':T':J ::;il,:i f :: il":ff; :[';.,"*1,,*.lat U )/"., *" not sJ-e peer.o{i the -ost supef;urallayer ot the
l"naiui"t' "na
tul" "
good look at the deeper layers Are ihey turnrng prnK
lij-rno'"tf 'f *, yo, h*e to take the sandwich apari because you oo nor
n"ue ette"tive le.ostasis Never rely on the patienfs cloiting mechanlsm
i" "".0"*t"
for ine{fective packing The besi time to ach eve
l"#iJJ i" r"*" vou leave the oR' noi iwo hours (and 12 unds or
blood) Later'
What if your packing doesn t work? Fitst' remove the soaked packs
*" u1l o""'*a l*p""ithe injured area.once more Did you have a gooo
sandiich sotiaty supporied by surroundlng siructures' of did you build a
"f_to"ting ""na*i"l','
in .id_air with no support? Do you need lo add more
o"'"-f."iSf,ouf a vou uaa packing {rom within or lrom wlthout? ls lhere an
ii"''"i "-""J*
,i' tn",",,'"a a'"at lttlre'e is' yo' musi dealwiih it directlv
,"1"" """n"i
*.*"i'c technique can you do something eLse to help
i.t',a" aii"o'"n" naa a topicat hemostatic ageni? A blind hem.ostalic
"r,lr"" *"t""u
"""0 *"it ag;in uniil you are sufe that you have ef{ective
bleedlng conirol
I serting a blittd helnosttltic (figrre of 8) suture
Use a blind hemosiaiic suiure to conitol a bleeder ihat is eiiher invisible
o, ias retract.a inlo the tissue You cannot see the bleeder nor can you
;;; ;;;;;. 'i, but vou can imasine whefe it is After usins brrnd
t',".o"tuti" ",ltrt"" "o
*any iimes in eJective.and emergency surgeryi you
.uv f""i"onfia""t tl"t vou know ho* io do ii well Chances are' you
don'ii here are some useful pointers:
a Make sure the anatomical situation is aPpropriaie for a blind'
;";;;; ";*".
lf the bleeding is close to an unexposed malor
"""""i "f*"y" assr.rme that lhe maior vessel is the bleedet and
Be paranoid about Your PacKs
a
TOP KNIFE The Ari & Craft of Troumo Surgery
lJse a monofilameni suture that will slide through the tissue ratherthan saw ihrough ii. Strange as it may seem, the keyto success is notihe suture, bLri the sAe ofthe needle. Choose the biggesi needle thatis appropriate for the situation.
a Place your first biie as closeas possibe to the sil€ ofbleeding. The purpose oflhls bite is not to achievehemosiasis, but to gain agood purchase on the tlssueso you can litt it up by gen ypulling on the suture wlihyour non-dominant hand.Now you can see on whichside of your first biie thebleeder is spurting. Yournexi bi ie wrl l be forhemostasis, and since it iswel l - targeted, i t wi l dousefulwork,lf anyone ever bothered to teach you about blind hemostatic sutures,you pfobably know that your aim is to end up with a figure of Icorfiguration that runs under the vesse proximally and distally to thebleeding site. This is nice in theory, but in praciice you can never besure in which direction the bleeding vessels lies. That's why ihey calli a blind stitch. Don t be disappoinled if you end up need ng morebiies. ll is okay to inseri 3-4 bites instead of two, as long as the biiesare cose together and lhey work. We cal ihis 4-bite suture a 'figure
o f 1 6 . 'Often, pulling on your blind suture w ll siop the bteedirg. You mustthen decide if you wsh to use it merely as a temporary hemostaiicmaneuver or te f as a permanent soluUon. l f you decide to t ie i i ,remernber to eave the ends long because you may wish to remove tlater.
While insert ing a bind stich, plan your next hemostatic alternative.Experience has taught us ihai il you have noi obtained hemostasis wjih
a
2 Stop Thot Beedins n
Aottic clafiPittg
Ao ic clamping is one of the traditional heroic maneuvers in ifauma
suroerv. Use it eltier as an adiuncl to resuscitation in a crashinq patient or
i*"oriur pt.*i..r contfol in rnajor abdominal vascular lrauma You are
'-.'i"l' '. i*- r'.. - oroperlv co'rlrolll-e sJoraceriac aodom:ndl aorta i
V"" " t i "-oi ' i . t Ln" l i 'sr ' ime-ir a berlv lul ol blooo LFarn and orauL'ce
the lechnique under eleciive cifcumstances
Use aoriic clamping judiciously, noi reflexively When used as a
resuscitative adjunct' ii temporarily corrects the numberc on the blood
0r""""t" t*it"t, O* "t
the pfice o{ global visceral ischemia
four bites, you are not likely to achieve ii with ihis siitch Don'l Jlail' Try
something else
As with any maior bleeding,
the best inrmediately avaibble
tool is Your hand Pull the
stomach downward and bluntly
enter the lesser omenlum In rc
avascular Poi(ion. Feel the
aorta Pulsating imnrediately
below and to lhe right oi the
esophagus, and compress it
againsi the sPine. lt You are
occluding the aona as a
resuscitalive maneuver' manual
compression is often good
enough. li Yotl need formal
aortic control, Proceed wiih
transabdominal suPracellac
aortrc clamPlng
filTf,I[of " h..ostatic stitch sains purchase on the tissue
TOP KNIFE The Art E Crofj of Troumo Surgery
The key anaiomlcal consideration in supraceliac clamping is that you arecjamprng the lowermost thofacic aorta, but doing it ihrough the abdomen.As lt emerges between the diaphragmattc crura, the aoda is enfotded bydense neural and fibrous tissue. In this particujar aortic segment, it isdifficult to obtain a good purchase wiih a clamp wiihout dissecting aroundthe aorta. Your best bet, iherefore, is io go higher up, into the lower chest.
Clamp the lower thoracic aorta through the abdomen
lf you have time, mobilize theleft lateral lobe of the liver byincising the lef t t r iangularl igament. Thrs improves youfwork space bui is not essentialto gei to the aorta. Biuntly openthe lesser omentum immediatelyto the right ofthe lesser curve ofihe slomach, and insert aDeaver retractor into the hole.Retraclion of the stomach andduodenum to the left exposeslhe posterior peritoneum of thelesser sac and, underneath it,ihe ight crus of the diaphragm.
Palpate the pulsating aortaabove the superior border of thepancreas to or ient yourself .Blunt ly make a hole in theposter ior per i loneum; then,using ei ther your Jinger or bluntlipped Mayo scissors, separateihe iwo limbs of ihe right crus ofihe diaphragm to expose theantedor wall of the lowermost
2 slop rhoi Bleedingl I
Using the fingets oi Youf left hand'
create just enough space on lrom
sides of the aorta to accommodate a
clamp. That is all the dissection you
need. Take an aortic clamp ano guroe
it io the correci position using the
fingers ol your leJl hand as a guide'
Clamp, and check ihe distal aorta lor
The aortic clamp iends io lall
forward inio the wound Encircle it
with an umbilical tape and secure the
tape to the drape over the Patrenfslower chest to immobilize the clamp
T H E K E Y P O I N T S
) Begin wiih the simplesl hemosiatic opiion
) Bleeding control is a graded response
) Be ready wiih an alternative hemostatic option'
) The finger is mighiier than ihe clamp
> Determine if the bleeding organ has a vascular peorcle
) Learn to distinguish belween a small pfoblem and BIG TROUBLE'
) Don t f iddle- be a fock
) Always err on ihe side o{ caution
'fr to, *"nr rn. ̂ rt & crofr of Troumo Jurgery
!
I
Chapter 3r - T t 1 1 , : r
Your Vascular loolKlr
Hutuall beings, who ate almost utique in hazting the'ot,ititu
to tria froa th? etpeie (e of olhe$' are atso
i; ;' ; k;i i ; i;; ; i ;: ; ; ;i p pi'[ n a i s i' ci i' a r i o n t o d o' o
- DouSlas Adams
lmaoine voJ'se p,eparlng Lo 'epair a gunsnot injury lo ihe Iemo-al
""";;il; ;;:;;; patieni has ar arte-ioveno'rs tisrLla jus' berow Ihe
il;is;"i; Yo,u feel a strons thrill and hear a bruii definitelv what our
residents call "a greai case '
You have a small probleml no angiogfarn oi the injured area Com€ to
,l'"0 ot ir, rou have neither heparin nor monofilament suture You doni
"u"n t_"ua
" o-o"t u"""Llar clamp Your greal case is 'aoidly becon'ng a
nioit.".". Ho* wourd you leel ;' the on'y vasuula- ools you hdd were
",r"." ti*
"orron "utr,res or stra'gnt need'es ard a oai- of cr'ide non_
crJshino crdmps? Can you 'naglne graobirg a sca'pel and lus'g-oirg lor
ii.l"i-,i"J """'" I l'.'is exactiv wnar J B Mu'ohv dn ama?irq cFicago
;; ; , i l ; ; ; ; ; t H" r xed a remorar arenovenoLs i istrra armed olrv
f f ; ;"-" ; rro* 'eoge ol tne analomv' vea's ol practrcirg vascLlar
repai's In .he laboralory. and sheer gJis Tne operaiion look 2 9 rours ano
went smoothly with no compLlcalons'
More ihan a hundred years laier, you have a dazzling array of vascular
instruments at your disposal when facing maior vascular trauma But you
"""""i .".. i"'""
" f"i"fated poPliteal artery and forget that ii belongs to
a criricatty inlurea patient who also has a fractured pelvis' a contused lung'
and possibly an inlracranial hemofrhage'
Tn,s cnaoter wi l , l r - t acqJarnt you wt1 Lseru general pnrc'ples [o
. ' , .J" "o,
*n"n coming lace_lo_lace wth a vasuura' n 'ury ' We assLmF
J"" "r."
=.i i.r. * t. o"iic va.cu ar recnrioues ano will show you low lo
liroi i"" i" +" u*-. s lJat on secono' we wrll p'esent a u"efrr toolkil
TOP KNIFE The Ad & Croit of Troumo Surgery
of technical oplions for damage control and definittve repair of vascularinjuries. Remember, a good outcome n vascular trauma depends .fore onclear thinking and keeping piorities slraighi than on cool gadgets andelegant moves. Keep your vasculartoo kit in mind as you learn to dealwithspecific vasculaf injuries in subsequent chapters.
Sequence and pliodties
Much l ike any oiher trauma operat ion, avoid making 'exci tng
discoveries' when dealing with major vascu ar inj!ries by following a we[-defined sequence of steps.
BleedingConlrol
Bleeding and schema, ihe two manifestatio.s of vascuar trauma,represent diffefent priorities. A bleeding carolid artery is an immediatethreat to the patieni s life, and you must control it NOWI Not so with anischemic eg from a superficral femoral artery injury, where you have aw ndow of several hours to save the leg. Th s is why bleeding js part of theABC of the primary survey of the injured patient, while ischemia isn't.
Bleeding and ischemia are different priorities
Grafr
,<v ?)J ,,t,,^ )t ./a- I
o g o { _ T J + ( f p iExt€nsile Delinilive
ControlDecision
Control external bleeding
Obtain initial control ol
external hemorrhage bY simple
digital or manual Pressure' lf
possible, rapidly iransler resP'
onsibility fot comPreasrng rne
bleeding vessel to an aaslstanr,
and preP the hand as Part of
the operaiive field Your
assistant can then connnu€ to
apply pressure while You make
an incision Proximal io (or
around) ihe comPressing hand
to expose the iniured vessol
g vour voscutor roolkii I
groin, supraclavicular fossa'
axilla, or neck. In these
localions, manual compression
is less offeciive. lnsert a Foley
catheter into the bleeding
tract, inflate the balloon unill
bleeding stoPs, and lhen
clamp the main Port of the
Foley. lf the wound is wide
and the balloon PoPs oul'
approximate the wound
edges around it with a stilch
to help hold it in place
Use a balloon catheter when the ble6ding source is deep and the wound
" ;;;;;. ffii;;;nd), especia'v in transiiron;"J:L?,:::::;^:,1':l:
(tI \ l\lr*
-" *n t"aponud" *ntrols external bleeding in kansition zones
TOP KNIFE The Ad & Crofi of Tro!mo Surgery
Before you begin
Do not beg n a vascular exp oraiion wthoui comp ete knowedge of thepatient's trauma burden. How much iime has passed since the injury?How much has the patieni bled? How urgent s the bra n contLtsion? Whatis the plan for the fraciure if the extremiiy you are operating on? you mustincofporate all this lnformation into your decision-making or you wi end upwftn an awesome vascular reconsiructron - rn a dead paiieni,
Know the patient's total kauma burden and physiology
Proper sequencing is a huge factor in penpnerar vascular traumabecause injuries to |mbs typicallyalso i/rvolve oones, nerves afd soit trssle.As a general rue, bone alignment conres before vasculaf repair. Fixnofract-res invo'ves s,ch lLn acLvtres as ha. rer i rg, r immrrg and ct^ iser ing.moving bones, and other tricks that a sio suture line does not toleraie verywpl l . So, i l lhe hmb s.or grossy 5cremc ard ihe pdnred orhooedi;procedure is short re.g. erter'lal frxatronr, let the o.thooediu sLrgeor do hbefore the vasc!lar exploration. tfthe timb is grossty ischemic or ifthe injuryis actively bleeding, you have io go f rst. Controt the injured artery, insert atemporary shunt, and do a fascioiomy io increase ihe tolerafce of the limbio ischemra. Let the odhopedic surgeon achieve bone alignmeni, and ontythen do the deflnitive vascular repair on a stabte extremity.
Align bone before aderial reconshuction
Angiography
Preoperative angography is noi an option for a hemodynamicalylrnsiab e or actively bleeding patent. If a stable patient, get an ang ogranrd you can, especially if you aren't sure where the injury s. Consider apatient wiih multiple gunshot wounds or several fractlres n the sameextrernity. How willyou know where the injury is without a road map? Witha srngle penetrating injury, ihjngs are sjmpler because you can find iheinjury wiih a limited exploraiion, so you can skip the angiogram.
3 Your voscuLorroolklt H
Depending on your experience and the local citcumstances' you have
three options for obtaining an angiogram:
1. A single-shot angiograri performed in the ER _ rapidly becoming a
losl an, e"i",r"r study performed in the angiographv. str l :
":^^9:_
"ndovascular inierveniion could preclude ihe need for open reParr'
a ;;;;;;" ansiosraphv b1, cannulalion of the exposed aderv -
" o""il!"rn"
"t" oL ai"ned by clamping the inflow beJofe injectrng the
dv".
Pre-emPtive f asciotomy
Consider doing a fasciotomy before beginning the vascular reparr' nol
*f,i" "".p"*"""a "v"arome
L clinically obvious When operaling on an
i""t"." ,r'ri "ttt, ,;, .ften know ihai the formal repair is going to take
ii"". i""r. ""f""'"""""
of action is to do a pre-empiive {asciotomy
A popliteal adefy repait is a good examPle' Regardless ol your
"rp.rlni", poprit."it""onstructions always end up taking longet than you
"ri"li"o in" unforgiving naiure -of
these iniuries and ihe paucity of
collaterals around ihe knee vrrtually guarantee yor'r will noi finish this
;;il il;"i a fasciotomv Be smart Do it before the vascular
we do a fourconrpartment fasciotomv using I
d:]bl: Jl"l:i::
*"';q; Pr""" vour iaterar incision :tC'*'l"lfll,y-:"1':::::i11"li:rcia all the way down to thetateral ;o rne edgF o' the tbia OpFn the ras
""ni"' ,f,"", 'a""ity and incise the inlermuscular ::t:l#*f^-+*H
;;;;.;;"; 4t","' "o'p"'i'"'.t'
Avoid da-ase to rh
rve ihat lles l! imity io th of ihe fibula\ Then, make a
ffie medial edge of
;; an angiogram if the patient is stable
t<z$ol'.. =r
ToP KNIfE The A.t & crofi of Trourno surgery E cf"^h '<-?tw^
. a / , . /to lhq greater sapherfous veiny'nor pad of tnisUsrng'lhe cautery..6erach the loleus muscte iro,r1
the modial aspect of ihe tibja to decompress the deep posterlorcompartment.
Extensile exposure and key landmarks
The fundamontal pr inciple of vascular explorat ion is extensj leexposure, which means ihat you must be able io extend your incisionproximal ly or distal ly along the same axis as ihe of iginal incision. The
the iibial shaft. Injury/ncrsron, so be cafoful
obvious examples arelower extremity incisionsalong the medial aspecioi the leg. Using iheseincisions, exposure ofthe superftcial femorai,popht6al, and Ubialvessels can easily beextended into each othor
In ihe upper extremiiy,subclavian, axiJlary andbrachial exposures aresimilarly extensile. Avoidnon-extensrle exposures,such as lhe poeter iofapproach lo the poplitealve$els or the transaxillaryapproach io the axi l laryartery, because they limityour access and restrictyour opiions.
Do pre-emptive fasciotomy before poplitear anery repair
3 Your vosculor Toorkil H
..H::1,::::""J l'"3:,i:'::T ;T"""l"li :T'J"'n::;l l:1 iT.-:l:f i:::it'::".m,:*if:i:' ;: J,::':::iT:fl :i::;;::ii:rtli:l'*::J::"1fi ":lil;:15::TJl:,""":':.,:ff :a"ria""'t a+Oq* Find lhe posterior aspccr ot tne {emu' or libia' and
i""'-ff :*-::rm"""Jff .;ff i;111"T:J-'j:ff ::;:ll"Jl;t*ff ffio.*"",*": jT;:iT::'.*:"??"Jt"1li?;,lli.il,Tl;"i #;;;;j';" ;;
"'tremelv 'rse{ur concep' whe. vou r€ n troubre i.,'
unfamiliar territorY
Proximal contlol and anatomical barriers
What is definitive vascular conlrol? ll is the accurate placement ot
u"""ri", "t"tp"
(or olher atraumaiic means of occlusion) across tne
i*t* "nO
outffo" tracts of an iniured vessel Proximal control is key
Fnrrrino a nematoma w[no,, ,''"' oot"'n'nn O'o''tar Lonfo away lrom the
lt"".li"rr" '" "
ur"" mislake thai often leads Io excessive blood oss
J^"rn"t i :"a tumor;ng pan c :arogenic InlJry' a ld soFetrmes
Prevent voJr drssecton {ro- beco'nlng a search ano oestroy m ssion
O, "it"';"g
orox'r"al conrrol o'risrde tne hematon'a Il'aI surrounds tre
ti,-t. ""t:"
l" "'"g"
terrrlory where tissue pranes are norrnal and
giaiua,ty aouan"" tow"td tne n;ured seg-ent
Experienced surgeons go beyond anatomical baniers lo get proxlmal
""*rli V"", you iu""""J it ' another key concepi Many anatomical
"irultur"" ""*" "" u"t'iers to the expansion o{ hematoma consider the
Know the key an6tomical landmarKs
TOP KNIFE The Art & Croft of Troumo Surgery
inguinal ligament rn penetratinginjuries lo the groif. Betow thelrgament you wi l l f ind only blood,sweai, and tears. Above it, youare in vtrgin territory where youcan eas ly isolate and coniroltheexternal iliac artery. The peri-cafdium is, similarly, a barrier tothe expansion of a mediaslinalhematoma, and the diaphragmblocks the extension of a midlineretroperitoneal hematoma. Goto ihe oiher side of anatomrcalbarriers to {ind easy proxima/
A useful opiion for proximal control in the limbs, often fofgotten in theheat of battle, is a pneumatic tournrquet on the upper arm or proximalthigh. Usirg it sar'es olood and sirnplifies rhe d,ssectio.r. Orce vou haveisolared and c amped trp irlrred vessels. def ate tl-p toLr'l,qLer.
Distal control
How importani ls distal control? li depends. Usually pfoximal controlalone does not dry up ihe operative fietd because back beeding fronr thedislai vesselcontinues to give you grief. The patieni wil not exsangurnaie,but you will not be ab/e to do a vascular reconstruction in peace.
For ihe aorta and iis proximal branches (e.g. subclavian and com..oni|ac arteres), proximal c/amping serves only to convert fierce audiblebleeding into weaker bleeding, but you still cannot see ihe injury well, andihe patieni is losing blood at an alarming rate. you mlsi obtaln distalcontrol. Do ihis outsido ihe hematoma if you can. lf not, expose the injury
Get proximal control outside the hematoma
unde. pro).ima' conkol and gai4 d stal control lrom within the I'emaloma
i""'"^i to"rtion, wne-e distar conkol is dfticult are the distal rrle-nal
"'"loiio "i"rv, .uu"t,ui"n artery and the a'ge verrs ol the pelvrs
For distal conirol {rom within the hemaioma' choose the technique-thal
mt"l';li:xru!T;i"1,fl",;"il1ll'ff :;i'f i:"il;",ii;l"*# fiol""|lt li"n"rtv cathe-ier connected to a 3'wav stopcock) rnto
ii" "rrrr"*i ""tf
ffti" l"st techn ique ' frequently used in eleclive vasculaf" "*rV
"ff""" y""
" n"in distal controlwithout having to dissect out the
Exploring the injwed vessel
3 Yolr voscuorToorki i n
Your saJe dissectionplane along an artery
is the Periadventihalplane directly on the
arterial wall lt will
carry you saJely from
uninjured terrltory lo
the injured segmenl
without lacerating the
vessel or ripping off
branchos, You knowyou are in this sa{eplane when ]/ou see
the pearly_white arlenal
wall wiih the vasa-
G"lnillotr.inut u"tloon for problematic distal control
, - r ' - . } . : : i
Vf-=,,au
IOP KNTFE The Art 6 Croft of Troumo Surgery
As you enterthe hemaioma, de{ine the injury by rapidly answering thfeequest ions:
a Which vessels are rnvolved? Artery, vein, or both?a How bad is jt? Laceration or comptere transeciion?a Where are you? Are there ma]or branches, joints, or other structufes
nearby?
You cannot assess an arterial injury by external inspectton. This isespecially true in blunt traumar where the artery may appear intact on theouislde yet hide a disrupted intima on ihe inside. you must open the arteryand define ihe extent of intimal damage. With few excepiions, yourarteriotomy will be .long itudinal. Make sure you see the full length of theint imaldamage.
Once you have defined the intury, carefu y debride the injured walt backto healthy iissle. Don't compromlse on intlma that looks ,almost normal,or is slghtly bruised,' because you are buying yourself and your patienteany postoperative thrombosis. There are no grey areas here - the rntimais either healthy or it's not.
Define the full extent of the vascular inlury
Developing a work space
Remenber ihai you are not oxplorlng the injufed vessel iusi io have alool ar,t. You are gor'1g lo wo-.( or ir. ano you 'leFd a worl space. Alaparotomy or thoracotomy automatica ly provides you with an oper cavtylhat is your work space. In rhe errremiries ano tl^e rec(, tlere a.6 10ready-made cavities, so you have to ca e one out,
Develop your work spacs in siages. First, make ihe incision. Then,deepen it into the subcutaneous tissue and rncise the d66p fascra. lnserta self-retaining retractor and continue your dissection to isolate theneurovascular bundle using ihe key tandmafks. As you make progress,coninuousty reassess youf emerging work space. ls the incision lonqenough? Shoulo yoJ re ocare rhe se{-relaining refa{,to. ro a oeepe;
3 Your voscuror Toorki El
ffi:Hlii!## ::: ii:+: H :iH3T*"i"".#[:inlT,',Ji[$i..""?TJ"T""i"'.1"*Y,"i.'$:l*l*ruru[lt:*:"ll:infi:,:H:""j;H' l[, ;:::::[:T*, ,ne incision and optimize
The key strategic decision
Now il s tirne for your strategic decision' the choice between vascular
aamaoe control and definitive repair - a simple enough concepi' but otten
a iougn declslon
Frrsi, consio€t the tyPe of -epai reouieo Fo'mal vascular repairs come
.n '*o ii"*,", "i'p" ino :".0 * I "lTllljllii":.i: :?:;:",*:::l';lrne thai can b€ completed quickly even uno
such a lateral repair will work _ just do it
A complex repaiis a\tascular anastomosis (or mors ihan one) Anend_
a-"nJ "n""toto"i",
a Patch angioplasty and an iniePosition gratt are
:*it,:",:x;ir*:ll:':;;JJ3#i;i:Jl::'i"'"iT::;",'::;r;'e;';;.';,"ft ';
"..egu'opath c pateni wno wrlr ;ust breed on and on
i--',-* "",r.i"
,t* tniJPaiieni needs io be in the intensive care unit'
;;;;;;;; '"""""''"ted not or the ope'at'ns tabre rosins more bood
"'"i i""ot ng ptog*""'ve'y hvporl'€tric Ynu'nusl ba l oui
Second, consider addiliona laclors ls tne paiienl unslable or'acrveLy
fr"iorg i" "n"th* "*'ty?
ll il'e arswer is ves -damage cont'o,s-your
:lll'i::;":"",",::l;J;'R::'"fi::.il"J"',:XT,,m"ii f :'"XnX'i:,""
"t in""" 0"".*"" ' l no' aga'n choose damage corlrol
Gradually develop and optimize your wolk space
illlilil"",, "o.otex va3cular repak and damage control
TOP KNIFE The Ad & Croft oi Troumo Surgery
Vascular damage control techniques
The two major damage controi techniques for vascular irauma afelJgatron and shuni insertion.
Ligetion
Ligation of an injured vessel is olten a no bfainer. The exlernal carot/dartery, celiac axis, and iniernal i iac artery are obvious examples of arteriesthat can be ligated with impunity. Other arterles, such as the subclavian orbrachial, can be ligated wlth a low risk of limb{hreatening ischemia. lf youare forced to bail olt bui plan to repair ihe vessel tater, don't ligaie ii , usea temporary shunt instead.
Ivlosi large veins can be igaied wjih impunity of with accepiableconsequences (such as leg edema). In ihe past, repaif of the popliieal veinwas vrewed as cr!cial for a good outcome with popliteal aderyreconstruclion, but this sacred cow was slaughtered long ago. Thefe areeven reports ol successful ligation of the podal vein, although this lsprobably one of ihe very few visceral velns ihat you should repair if youcan. Remember, ligating a vessel is not an admission of defeat; ii can bea sign oJ good jLrdgment.
Ligation is not an admission of defeat
Tefiporary sh nts
lf you have liltle vascular experience br are operating in austerecircumsiarces, a temporary shunt may be your best opiion. Insert a shunlwhen the patient's physiology is prohibiiive, when orthopedic alignmefi ofthe bones precedes ihe aderial repair, or when you lack the resources todo a complex reconstructon.
Shunt maierjal is not an issue; use whatever is immediaiely available.We have successfully used pieces of nasogastric tubes, suciion catheters,
3 iourVorcuor roo ht E
cafotid shunts, and silastic Tlubes We preter to use an Argyle snunl
illil"tr" in"l ir*io""ause we use it-resularlv in carotid sursery' and.
,; . "^""
t" handte. However i-l ore oI Lhe most soeclacular cases oi
-ri""".il ""*, "n ""
we have seen a niltdry surgeon in he lield 'sed
l-segment or naso;astric tube to shunt a transected femoral artery in the
grorn.
easier to control than fore{low). Now, fix ihe shunt in place The simplest
technioue is to secure the shuni to the artery proximally and distally with
n"1"" "ir
,"" Howeve- th:s s taumaliu to lhe drle'idl wal a,rd wi| ater
,*rit" ".a,**,
O"O*emerI of the artery oeyo']d rhe rigalure line when
".1':".""" tl" snr,r-. ol prelerence is Io pass a vessel loop twice
aro:nd tne s 'runted ar le 'y and gent 'y ci lLh f w1h a large mela'c lrp or a
nrmm"t tournlqret. Now' asless the dislal perfusion by lisiening for a
Doppler signal over the outilow artery You fe done
Shunt failurgshortly aJtef insertion is due io one of the following:
a lnadequate infLow (proximal injury or tesidualthrombus)
i Compromised outflow (residual clot or mlgratlon of the shunt into a
disial artetial branch)
lnsert the shunt using a
wel l-def ined sequence ol
sieps. Begin bJ/ clearing the
inflow and outflow tracts of
the injured arlery wrth a
Fogarty caiheter, if available lf
not, gent ly squeeze the
proxinral and disial ends of ihe
iransected artery lo exPress
clot, and release the clamps
momeniarily to flush out botl
inflow and outflow Choose a
shuni of the largest d|ameter
ihal will fii comfortably in the
vessel, t r imming i t io the
desired length. Genily insert Lt
into ihe distal, then Proxrmalartery (since backflow is
a
a
TOP KNIfE The Ad & Croft of Troumo Surgery
Obstructed shunt (angulatron due to excessive length or ligatures ihatare too trghil.Shunt dislodgemeni (presents as a rapidly expanding hematoma).
Clear lhe inflow and outflow hacts belore shunt insertion
Def initive repail techniques
You have ihree opiions for definitive repafii endio-end anasiomosis,palch angioplasiy, or interposriion graft. An end-to-end anastomosissounds like an gxcellent choice because rt involves only a singlestraightforward sutlre lire. Ljnfodunately, with experience you will lindyourself using this solutior less frequently ihan you think. In youngpatients, the ends of transecied arieries retract a surprising distance,creanng a large gap. The inexperienced surgeon wil spend t me mobilizingboth ends of the transecied aftory in a herolc effort to bnng them togetherThis entails add tonal dissection and sacrificing branches atong the way.Despite these afforts, the resulting end-to end anastomosis will often beunder considerable tension and will have io be redone, this time using aninterposition graft. Therefore, in vascular trauma, the best opiion forcompleie transection of an artery is often an interposition graft,
Transected artery = interposition graft
Patch angioplasty is an optlon to keep in mind, especiatly if at least hatfthe circumference of the artery is still intact or if the vesse is small. Werarely repair a laceration tn a brachial or popliieal artery wthout a smallvein patch, because even a transverse y oienied latera repaf wi I narrowthe lumen of lhese smal vessels,
Before you begin ihe reparr, pass adisially, and then flush the vesse withcatheier wlll not only evacuate coi, butfacilitating your repair.
Fogarty catheter proximally andheparinized saiine. The Fogariyaso will dilate a spastic vessel,
3 /our voscuro To"rki g
Systemic heparin has a bad reputation in vasculaf trauma' raising fears
o'clusing U'eea,ng In Ihe adlacent trdumatiTed soft {rssue or In remore
'ni, nes. Hlowever, wfren deal:ng wrh an isolat€o arler;al Injury' especially il
tir, t"o"', "
n"t"n " "ke
rime' give system c heoajn to protecl Il'e d;stal'microcirculation
Popliteal ariery repairs are a good example where
sysiemic heparin makes a difference
Oo vou l'ave Io tepair injured veins? lt is a 'urury rol a mJsl ll a vein
" ,. i"*i'"" a co.pre* ,epai' t may not be wonh ine toJble These
,J""1t" "]"
t""n"tnrt rno'e derand'ng lhan arte'ial reconsrruclions often
*in "i"t"i"""J,'i
*tencv' and mav oe 'nnecessatv lr Ih€ palient l'as
.ti* "'r"""
ti" ,"qui," """ntion
susta neo a srgn lcant physiorogical
'"""rr, "ih"]0""" "
t'" oR {or many houts' ligaie lhe Inlured ve n w'thoul
hesitaton.
l{ vou decid€ Io iaduge i.] a combinod arleria' ard venous reparr' lhe
u"nou" ,"con"tru"rio't should come {irsl because a thrombosed ven
"""noi o"
"ff".tiu"fy cleared R6membef io interpose viable soil tissue
Setween the ve"ous and arieial tepa rs Io nreveni a fislula
Vein repair b a luxury - not a musl
Working with grafts
Choce ol qrah malerrar rs a mapr collroversy n vasculat irauma No
.""' ;J";"" ""t
a syntherrc lrair oelow ll-e Lnee or drstar Io the
"l"rfa.t i"""r"",n" *ssels are ioo small; 4mm synihetic grafts simPly
a.nii *o*.. ft,i" locuses the controversy on the femoral artery The
irooon"nr" ot u"in sr"ft" emphas'ze how wel' Ih€y worK altho'lgh Ll'ere is
.n .ooa ev'derce ihat ll_ey do beiter il'al synthet;c gra+s ri young
;:;;*';;;"t;"t oufrow trac$ rhe p'oponents ot sJnlhet:c sta{is
:;;;; ;; ;" Ihev rarl s nce n Ihe preserce ol nleclion and
"; ;" : ; ; . . ; ; " sta{ i ;essicates ano.dssolves resLr ' t :ns :n sudden
hemorrhaqe. A syrthet c gral t ia i ls gradual 'y by lorm ng a
oseudoaneu'Ysm A4oIl'er aovanlage o'1he syllhetc graft is €{pedlercy
Lr, -o"r"o*
prelerence rs synthetrc grah lor lemoral artery
TOP KNIfE lhe Art & Crofl of Troumo Surgery
reconstruction. The tfuth is thai i does not matter which materiaiyou use,as long as you do it well.
Graft proteciion is a cardinal principle in vascLrlar trauma. Whenptanntng your reconstruciion, femember that an interposiiion graft in atraumatrzed and coniaminated fleld inviios disaster. you have io route thegratt through a clean fieid or cover it wth wellvascularized sofi tissue.Graft protection considerations may dictate ihe operaiive sequencelbowel repair and peri toneal toiet before an abdomlnal vascularreconsiructron; sofl trssue debrdement before an jnterposition graft in anInjured extremity. Occastonally, yo! may have to improvise anunconventronal extra,anatomic route for the graft to avoid either a heaviycontaminated environment or a large soft irssue defeci,
Vascular traur.a js esseniially the art of deating wiih young arteries thatare sofi, pliable, and easily undergo vasoconstriction. Remember thesernherent qualrtes when sewing in a gfaft. The technical princip e of drivingthe needle always from inside the artery out, so religiously taught ineleciive vasculaf s!rgery, ls trrelevant in vascular trauma. you won't raisean rnlimal flap in a healthy artery, 6van if you go lrom outside in. So, workrn whatever direction is nrosl convenrent, but always have tremendousrespect for the arteral wal, because ii will not forgive bad passage oJ theneedle or jefklng the suture sideways. The trajectory of ihe needle musialways be perpendicular to the arieral wall.
Do not injure the artery with your vascular instrumenis. pass a Fogartycatheter only a few cent rneters above and below the injury, and do notover'inflaie, or you wil denlde the healthy iniima. Close the iaws of avascular clamp gently ('only two clicks") so as not io crush the artefy.
A major pilJall with yourg arieries is s/ze mismatch. lt ls easy io inserttoo small a graft into a vasoconstricted artery, onty to laier reatize you havecreated a boiUeneck that inviies early failure. This is particulafy commonin the aorta and i|ac arteries ofyoung adults. Because the vasoconstrictedaorta will dilate later, make a consctous decsion io select a slightly largergraft than whai you deem necessary at the moment.
Vascular tr6uma is the art of dealing with healthy aderies
3 Your voscuo,rooLk ll
T H E K E Y P O I N T S
) Bleeding and ischemia are differenl piorilies
> Balloon tamponade conirols external bleeding in lfans(ron zones
) Know the patieni s ioial trauma burden and physrology'
) Align bone befote arierial reconstrucliofl
) Get an angiogfam if the patient is stable
) Do pre-emplive fascioiomy before popliieal ariery reparr'
> Know the key anatomical landmarks'
) Get pfoximal conlrol outside the hematoma
) Use an iniralumlnal balloon for problematic dlsial control
> De{ine ihe full exient of ihe vascular lnlury
) Gradually develop and optimize your work space
) Decide between complex vascular repair and damage control
> Ligation is noi an admission of defeai'
) Clear ihe inflow and outflow tracts before shunt insertion
) Transected artery = interposition gra{t'
) Vein repair is a luxury - noi a must
t Vascular irauma is the art ol dealing with healihy arteries
TOP KNIFE The Art & Croft of Troumo Surgery
Chapter 4
The Crash LaParotomY
Damn the totpedoes, full speed ahead!
Admiral David l. Faragut
In most surgicaltraining programs, you sp€nd much time in the OR with
,^-. , ,*" .v in nand. merr irv braslrnq away at 5uay eynrocfes whi le yoLr
i",.1# ,,i"o"rt'""'t op"ns tl^e correct liss're o'anes wilh a r'gl-t-a-gled
"i]-. r"
"""oot""""t *cl"r Irp or ar educated {'nqer' pretendlng you a'e
Ii"| ,a" """"1t*
*"t vo- cut ss''e . tie trots a'ranse relraclon and
-_r.r;e oowe, are all parl ol In" tecnrrcdl largudge ol ge'e'al sLIgef
A rrauma operarror is _oI an acce'e'ated v€rs'on oI the elect've
.r*"irr" it .-tr'r"" "
o tlerell I"cnn cdl langLage a'rd moct rmoortantly'
I i i " r"" trnnd""t ln this chdpler ' we dero'sirale tnFse d'{erenccs by
Lilng "
r";irl"t op"t"tlon' exploraiory laparotomy' and translaiing lt Into
ifre tleclnicat anguage of traurfa surgery Rapid alternations between
"*n-","a" "*-"" t t" -a_euvers a.rd rel iculous dlssecton are rhe
i" ' . """"" i" i ' i r " , nparolonv l l 's l ike dancing through a Iear m ne{ield
*iii. pi.yl"s oOOL/- on vour laptop Get the pictufe?
The oPerative sequence
Every trauma laparotomy follows lhe same methodical' pfactLced
operatNe sequence
/"r \,t(" .r ^'fibrr\"€ +,0;;;;1
\ - r-++^-I Exp ro€ t i on
" \ y :Exposue
Tenporary Bleoding
oeflnitive Repair
ControloamagsControl
E to, *",r, tnu on & croti of TroL,rno surserv
The key decision in ihis algorithm is the chojce between definitive repairan0 dan'iage conirol. The earlier you make this decision, the better for ihepatieni.
Gaining access
Enter the periioneal cavity ihrough a long mid/ine incisron, the Texasname for which is 'Hey diddle diddte, r ight down the middte., , The tessstab e the paiient, the fasteryou should dive jn. Take ihe scalpeland makea bold cut through the skin and subcutaneous t issue. l f you grab thedjaihermy to systematicaily barbeque subcuianeous bleeders In a patientwilh a systolic pressure of 60, you are probabty in the wrong speciatty andshould consider a career change. The hypotensive traunra patieni isperipherally vasoconstricted, and you are wasting time orj nonsense oozngwnile rapid intra-abdominal bleedlng continues unabaied 2cm below the tipoJ yoLrr diathermy. Sounds pretty st!pid because I |s.
The incision begins below the xiphoid, skrrts around the umbi l icus, andends above ihe pubis. An experienced surgeon uses ihree long andprecise passes of the knife to enter the peritoneal cavity. The first sweepgets you past the skin and into ihe subcutaneous tissue. The second passlands you on the liriea alba. Develop the abiliiy to gauge the depih of th€subcutaneous fat and ihe 'feel" of landing on the fascia witholt cuiting it.The third and last pass of ihe knife divides ihe linea alba to visualize iheprepentonealfat .
4 The Crosh Lopororomy
Tra:n yours" l l to ma^e tne ncisonl:Ke a pro l r ' r la(es Yo' l l rve or si \
.*""p". 'yo, a- or.ay O,t not yet ready lo 'prrme t ' "e '
The kev -anF.rver .s 10 cul in thF miol :ne whe'e the abdom'nal wa' l ic
,n,nn" '" , l lo ""ur 'n,o ,ne aboome" :s qLlckest Tnis rs cal leo "garnirg lhe
",,0i,"".,iO n"jr"*" of the midline is the decussation oJ the fibers ot
tt" unt.rioir""tu" sheaih lf you see muscle underneath your fascial
incision, sieer medially
Now, take advantage oi
a little-known anatomrcafaci. In most Paiients, the
periioneum just cranial to
the umbilicus is either
very thin ot has a delect
There is only very thin =
preperitoneal fat in thrs =-area, making lt the ideal =enor for enter i rq the ' - - - - - - -
peritoneal caviiy forca "=.:;==;-2')the elaboraie dance ='(often iaught in electivesurgery) of Picklng uPrh-"-oe; i tone ,m betwee. 'wo parrs o{ p c{ 'p- ard makirg d s 'al l n:c\ lo
l"iju-;. 5r-p1 po^e a frrqer irro rl-is oer'tone't defecl immedralely dbovF
tf'" u*lifi"u", "na
yo, find yourself in lhe peritoneal cavlty
tlsinq a parr ol l^F€vy scissors crr Ihe pFrfioreu_1 toge'he- wrth rhe
-J,n"o or"p"t i to.""r iai ' Lo l l 'e rul l exlent o{ the:ncision Use your ron-
i" . i ' "" i , i , "a 'o pusn ine Intesr i lFs oown Io prolect tnem tor youl
.i".""i"g ""i**"
ldeniiJy the {alciform ligament and divide it between
;;;; ; ;;'; """"""
to ih" tishi uppet quadrant You fe in the bellv'
ready to Rock n' Roll
ilf,Ih" u"tly "itt
ttr"e sweeps ot the knife and one educated finger
TOP KNIfE The Ad & Croft of Trourno Su€ery
A 7oor.1 of cdlttion
Tl_e.maior_pi l 'a l l our ing a crasr laoarororv is,arrogFnic:njury. The tehlalerdl lobe or -he l,ver rne srah bowet. ano thF braodF, a.e in j;oparoy nihe upper, mjddle, and lower parts of the incisjon, respectiveJy. On aparticularly bad day or if you are especia y gifted, you can jnjufe all rhreeotgans in one bold sweep.
lf the patieni has a pelvic fracture, entering a pelvic hematoma isgeneraly considered a bad move. IVake an upper midline incision,carefully peek into ihe abdomen, and extend your incision downwardbelow ihe umbi l icus under direct v is ion.
Enlerlng the abdomen through a pfevious laparotomy scar can be timeconsumrng and exasperating in a hypoiensive patient. The safe techniqueis io extend the lncision beyond the old scar into virgin teffiiory and enterthe peritoneal cavity where adhesions are tess tikety. Then, oper the otdscar piecemeal, after making sure that ihe lndersurface s clear andpushing adhereni loops of bowel out of ihe way. Even if you havecompleted your incision without mjshap, you may still face adhesrons ofbowel loops to the anterior abdominal wall. When these adhesions aredense or mult/pie, you will feel a liitle stupid engaging in carefuladhesiolysis while the anesthesiologist is punrping unii after unji of bloodinto your hypotensive patient. ls there a quicker way rn? yes, there is.
A creat ive solut ion in anabdomen with multiple old scarswould be noi to enier in themidline, bui make a biiaterals!bcostal incision (also knownas a Double Kocher or a rooftopincision). The inclsion i isel ftakes longer to make and close,but you will more than make upfor il by skirting around thetroublesome midline adhesions.
Stay away from old scars
4 The crosh Loporotomy Il
Once inside the abdomen
When you firsi peek into the open abdomen' all you can see is a
"p"gi"ni of fo*"f top" swimming in a pool of blood and clols Your fLrst
iiloi,ti"" "r" to u"t,i"u" temporary hemostasis and evacuate the bLood so
yoll can see what is golng on
The key manelver
raw is eviscetationRapidly gaiher ihe
smaLl bowel loops
outside ihe abdomen
ioward you (io the
r ight and uP) Don'tjust shove laparotomypads inio lhe oPen
abdomen wlthout evis'
cerating the bowel, an
act akin to throwingpaper naPkins lnio a
bowel o{ soup - and a
total wasie of iime
Evisceration converts the boody mess
allowing you to see whal you are dorng'
achieve temporafy hemosiasis
inlo a manageable work space,
Rapldly evacuate the blood and
Eviscerate the bowel early
Choose a iemporary hemostaiic iechnique based on the mechanism ol
nurv. In or.r ' r l - rat-ma begi, ] w' in empi 'car oacl i , rg Hand your assisianl
, 1i"" '**" t" ' to e'eva; l tse abdo-rral wa ' ol eaun qLaoralr i - IUrn
". i i " . . , ""
"Oo"-"" 'aprd'v Begi ' wit ts lne ' ig l ' ' Lpper qJad a,tr bv
.,"1 ' i ] * , , "r ,
t*o ou", 'n" ao-" ol the ' rve pJl ng ' ' gentrv loward
;; #; , ; t pac\s over vo ' nano a'ove ano iFen oelow Ir e l :ver '
i,""kli" iiont o"'"*," nutter' N'4ove to ihe left and put your non-dorninant
n"nJ "fou"
tf'" "pf""n'
pulling it gently loward you' ihen pack over your
TOP KNIFE The Art & Crafi of TroLJma Surgery
reiract ing hand abovethe spleen and left lobeof the iver. Create asandwich by packingmedial io the spleen.lVove to the left paracolicguiier and then to ihepervrs, and pack them,Al this tinre, the evis-cerated bowel remainsout of the way. lf blood isaccumulat ing on theevscerated bowel, thesource is a mesenlericbleeder. Deal wi ih i tdrrectly. During packingand whi le your non-dominant hand is retfactrng and proiecting the liver and spJeen, fee/ for anyobvious injury, and begin planning your approach based on this tactile
Empir ical abdominal packing does fot arrest major arter iahemofihage. lt gives yo! time to organize your efiort and divides iheperitonealcavity into severaldislinct areas you can explore systematically.Packlng works wel n blunt t ralma because the most l ikely sources ofhemorrhage are the lver, spleen and mesentery. Bleeding from most solidorgan injur ies can be temporari ly control led with ocal pressure, whi lemesenteric injuries are immediately apparent in the evlscerated bowel
In penetratrng lrauma, your best bet is to go straight ai the bleederGlance into the eviscerated peritoneal cavity to deiermine where thebleeding is coming from. You will then be able io achieve iafqeted ratherlra. bl:nd rempora.y herosrasis. pac^ a b,eeding sohd orgun o,,
In blunt trauma, begin with empirical packing
4 The Crosh Loporoiomy
contained retroperitoneal hematoma' Manually compress a {reely bleeding
u""""i. Ct"rnp "."""n,eric
bleedet some surgeons pack empirically in
penetrating traurna cases, just asthey do in blunttrauma We preierto see
eracily what is bleeding and address it directlr'
i
I
In an exsanguinating Paiieni,consider compressing ihe aorta.
Manual compression of the
supraceliac aorta through a,ho!e In
the lesser omenlum rs mucn sarcr
and as ef{ective as formal
clamping. Transfer responsibilityfor aoriic compression to the righi
hand of your assrsianl
Surveying the battlef ield
Once major bleeding is
temporarily controlled, raPidL)/
explore the abdomen The
ifansverse colon eltends acrossthe middle of Your incislon, and
its mesentery divides theperitoneal cavity into two -
visceral compartments The
supramesocolic comParlmentconiains the liver, stomach' and
spleen, The inframesocoLlc
conrpartmert contains the small
bowel, colon, bladder, and
f emale reproduciive organs
In penetrating trauma, eviscerate and go for the bleeder
Systematically explore the peritoneal caviiy. It doesn,t matter where youbegin as long as you maintain a iinear sequence that covers the enlireconieni of both conrpartments. Thls sequence sholld be rouiine andreproducible. You learn it in residency and methodically repeat it insubsequent operations, ln your sleep (and jn courr).
Begin your exploration of the infranresocolic comparrment by tifting ihetransverse colon cranially and funning the gut irom the ligament of Treitzdown io the rectum (or from the rectum backwards to the ligament ofTreitz).
TOP KNIFE The Art & Croli of Troumo Surgery
Two pairs of hands ,yours ard your assistant's' {lp each loop of bowel ina coordinated fashion toinspect both sjdes, payingspecial attention to ihemesentery The posierroraspect ol the transversecolon and the hepatic andsplenic flexures are notor-ious for mrssed njurjes. lfyou rdentjfy a bowelperioratron, contro thespillage with a soft bowelclamp. You typical/y smella colonic perforation b€fore you see it. Rememberto look ai the bladder afd femate reproduciive organs in ihe pelvts.
Pull lhe hansverse colon caudad to explore the supramesocoliccompartmenl. Inspect and palpate the llver and gallbladder, and palpateihe fight kidney. Then, inspect the stomach all ihe way up 10 theesophagogastric (EG)junciion and the duodenum (including whai you cansee of the duodenal loop). To fully visualize the duodenum, you musi do aKocher maneuver and take down the ligament of Treiiz. palpale theconvexity of ihe spleen and ihe left kidney. Don,t forget to inspeci bothhemidiaphragms and note any injury, as wetl as whether the diaphragm isf lat or bulging into the abdomen.
4 The Crosh LopororomY
Next, exPlore ihe
lesser sac. As Yourassistant holds uP the
stomach and transversecolon, Pul l ing them aPan
to streich the greater
omentum, go to the leti
side of the omentum (it is
typical ly less vascular),
and bluntly Poke a hole in
ii. This allows a good look
ai the posterior wallof lhe
stomach and the body
and tail of lhe pancreas.
So far, you have explored lhe petitoneal cavity- Underneath' the
r"t;;"'-ft"";;., a sepa;ate visceral compartment' is still lurking in the
Exploring the retroPeritoneum
To get to the relro_peritoneal siruciures, Youmust go behlrd the
intraperitoneal ofgans
Global exPosure ot the
entire retroperitoneum s
lmpossible, so the keyprinciple is limited
exposure of the relevantretrope ton-aal siftlcures
by rotating the overlyrng
intraperi toneal organs
medially.
Explore the supramesocolic and inframesocolic compartments
. Decide whjch retroperitoneal structure you wjsh to explore, guided by
clinical suspicion that it may be lnjured. your clinica suspicion is based o;the tralectory of the wounding missije or on the presence of aretroperiioneal hematoma. For example, any hematoma or blood staininqarou' ld rhe ouodenat oop mandates mooi, izd- ior ol-he seLond pa|. or t r ;duodenum and the head of ihe pancreas. penetrating injury to theascendrng or descending colon requnes mobitization of ihe enrire injuredside of the colon io examine noi only its posterior wall, but also theadlacent uretet How can you get the intraperitoneal organs off theunderlying retropefiioneum? By doing a medial visceral roiaiion.
TOP KNIFE lhe Art & CroJt of Troumo Surgery
Lefl6ided rredlalvisceral rotation (Mattox maneuver) .The east accessible area of the retroperitoneum s the mldljne
supfamesocottc sector, which contains the suprarenal aorta and itsbranches. lf you iry to get to the slprarenal aorta direcily from the front,you will have to transect the stomach and pancreas afd then strugglethrough ihe dense connective tissue and nerve plexuses surroundino iheaona. The [,4€tio' maneuve. altows yoJ lo ducomo ish rh,s erpo,ure s-p yby lifting the left-sided abdomiiat viscera off ihe posterior abdominat wailand rol ing them io the fghi .
Begin by mobi l iz ing thelower descending colon, as ina left coleclomy. Pu I the leftcolon toward you, ideniify andincise the white iine of Toldt,and rapidly mobi l ize thedescending colon from belowtoward the splenic f lexure.Continue your move upwardalong ihe same line, whichexiends lateral to the spleen.
Keep rehoperitoneal exploration targeted and limited
4 The Crosh Loparoromy
This move enables Youto roiaie ihe spleen,pancreas and left kdney
in a media direct ion
toward the midline Asyour hand sweeps rrom
below upward andmedially behind the lett-
sided organs, Your Planeis directly on the musclesof ihe posterior abdominal
ln most srtuatronsrequir ing this maneuver,the retroperlioneal hema_
toma wi lL do much of the
dissection for you. As it spreads laterally' the expanding hematoma lifls
the lefi sided ;iscera off ihe posterior abdominal wall, allowing you to
perform the maneuver bluntLy and rapidly
An expanding central hematoma does the disseclion for you
You know you are In
the correcl plane as long
as You can feel theposierior abdominal wal!
agalnst Your f ingediPswhi le you blunt ly dissectbehind ihe viscera withyour hand. Continue themedlal rotaiion allthe way
up to the diaPhagmatchiatus. You can then cut
the left diaphragmaticcfus laterally, and bluntly
dissect around the aorta
E ,o, *"nr,n" o,r & crofi or Troumo su,sery
wrth your finger to gain access to the distal ihofacic aoda as high as T6.This is a quick and easy way to gain proximat aorric coniroi wjihoutopenrn9 li.F chest. The comp,eted l\4atior maneuver gives you acLess toihe abdominalaorta as wel las most of i ts branches, includino the cel iacsuoF.ior me<entFr.c, re, , ,enat ano tef l i , iac aneries.
ll your target is the ao*a itself or its anterior branches, rotaie the leftkidney with the other left-sided organs. lf you leave the kidney jn place bydeveroprng your ptane anterior io it, you will restrict your access to iheanterolateral aspect of the aorta. The left renal vein and artery will be inyour way, and the Jeft ureter witJ be vutnerabte ro injury. However, if yourlarget js lhe left kidney or the renal vessels, leave ihe kidnev in olace.
Feel the muscles of the back against your fingertips
When you perform the N4attox maneuver for the firsi iime, you discover(yet again) a discfepancy beiween neat illusifations and harsh realitv.Don'i say we didnt wa,1 yor.r. Once you nave cla,nped rhe aor;proximally, it becomes a pulseless flaccid tube that is difficuh io identjfv ina large retooeritoneal lemaLoma. To -a1e maflers worse, a tnick laveiofperiaortic tissue separalF5 ihe suprarera, aorla l.o7l your dssectiorplane, and you musi divide it to gain the periaoriic plane. We advise vouto ga n t,rrs olane ai tne irJrarenal leve,, whe.p it is much easier to toeniifv.and tnen orocFed uo to rhe sup-arenat aorric segmerr. tr younihypoiensive tfauma patients, the aoria is constricted and considefablvsmalef ihan you expecl.
It is not uncommon to injure ihe spleen during a rapid medial visceralrotaiion, so examine it closely when you have iinished the manelverAnother classic pitfali is avulsion of the left descending lumbar vein whilemobilizing the left kidney. This treacherous vein comes off ihe left reralvein (LRV) and crosses over the left latera/ aspeci of the aortaimmediaiely below the left renal artery. lf you plar io work on ihe aortaaround the level of ihe left renal vessels, it is a good idea to idenitfy,ligate, and djvide this lumbar vein to avoid avulsjon durino retraction ofthemobilized left kidney.
j i . J l L\,,/ )rA
4 rhe crosh Loporotomv rl
Right-sided medial viscelal lotation "
Perform righl_sided medial visceral rotation in three distinct slaqes'
Each successive stage gives you progressively belter exposure ol tne
The first stage is the
classic Kocher maneuver,where you mobillze lhe
duodenal loop and head
of ihe pancreas ldentify
the duodenum and Incse
ihe posterior Periloneumimmediately laieral io it.
Insinuate Yolrr hand
behind the duodenumand head of the Pancreas
the right renal hilum Beware of injury
to ihe right gonadal vein as rt eniefs
ihe IVC at ihis level
The second stage of a righi_sided
medial visceral roiation is the
exiended Kocher maneuver, which
gives you wider exposure ol the
retropefitoneum. After completing lhe
Kocher maneuver, carry the incision in
the posterior periioneum in a caudal
direction toward the white line ot
Toldt, immediately lateral lo the nght
colon. Note that this white line is in
to begin lifting thom uP,anJ c"ontinue'molitizing the duodenal loop fiom the common bib duci
superiorly to the superior mesenleric vein (SN4V) inferiorly The hepatc
ttexure overlies the lower part of the duodenal loop' and you may have to
mobillze it too Now you can tefleci ihe duodenal loop and head of the
oancreas medially to see the IVC and
E ,o, *",rr rnu on & crofj of Troumo susery
;:|,.ff"",dt:irlHr;::##:"ffiil1^i"..iixili"iii;;Til:ifln: :",;"T:::;: ;i;,il;l: *::i:"'"'",'" "n.,'*iiJ,
_^ll: ]n|:O stage is, you guessed it, a super.exiended Kocher
Fri:{,ili:iiJi:,ili"]ii:",1""#,3":iJH::H'*:":r"iilti:ri:[:]r, iffi ::"."#::t,ff i l;;l;i*m*iri ;;:'il1;:iT".li";;"'"rero' c'ania'rv aro obJq*'v r'o'' rn.
"*u- J
To perfom the Catiell_Braaschmaneuve( do an extended Kochermaneuver; ihen, carry ihe incisionin the posterior periioneum aroundthe cecum. Now, gather the smallbowel 10 the rjght and craaiallv,and incise the tine of fusion of th;small boweJ mesentery to iheposterior peritoneum from ihemedial side of the cecum to iheligament of Treitz, a surprisjnolvshort distance. you shoutd nowieable to brjng the small boweJ andflgnl coton out of the abdonrenand swing them upward onio theameaor drest, a pretty remarkabjesrght.
---]h:--C.n:,tp*i*h maneuver begins ar ihe common br/e duci (CBD)ano ends at the ligament of Treiiz. Whenp-anoramic vrew or rie e",''." r,,"."""""i" ,"1i#0"',"J"'L,l rJl"rt":::":
to the infrarenal aorta and lVC, as wellas both renat arrefles and veins andthe rliac vessels on both sjdes. ll also provides access tothe third andfourih
Do a risht.sided mediar ni"""J .IiIiIIiIt"-!"!
4 rhe crosh Loparolomy g
parts of the duodenum ano the
superior mesenteric vessels lt is
an awesome exposure we
stfongly recommend that Youcarefully siudy, understand' and
memorize ii because il is ihe key
to approaching some of the most
diff icult abdominal iniuries.
The maior Pitiall with tight-
sided medial visceral rotatron rs
injury to ihe SMV at ihe root ol
the mesentery. Once You detach
the f ight colon from i tsperi toneal at tachnreni, i i is
hanging bY its mesentety aone.
An inadvertent Pull will avulse
the dght colic vein off the SMV
resuliing in unexPected bleedlng
from the root of the mesenterY
The Cattell-Braasch maneuver: from CBD to ligament of Treitz
Selecting an oPetative Profile
Now it is time to decide which operaiive pfoflle is appfopriale for your
paiientr de{initive repalr ot danrage conirol (Chaptef 1)'
Iniury Patterns Indicating the Need for Bail Out
Combined major vascular and hollow visceral injuries
Penettating injury to the 'surgical soul' (Chaptet 8)
High-grade I iver injury
Pelvic lraciure witf an e{pardrng peivic l^e-aloma
lnjuries requiring surgety in other cavities (chest' head' neck]
E ,o, *",rr rn. orr & croft ol Troumo su.ger1,
Temporary abdominal closure
*rh:]: "i:[iF:';Hig :":T:fl;, :::l?"5ffi :'ilr;f""il ff H:ff "i::;:i;:::' Jiil:i,iliti"' *"";;.;;il;"i ;
::i'f:":it!.i,qii"i,:"_'ii"*r#:,::ft li Jij:i:-;,":;; :t:provtdes a means fof collecting jnira-abdomicreaies a physicar banier beti,een ffiJfl j:l,i#:ijT:iii:i!;jlmass. This barrier prevents adhesion formatiof beiween ,f," l"*",1"j
f.#"i:,:JI** ihe window of opporiunity ro,
"",ry a.riniiv"
The vacuum pack isessent ial ty a sandwich.The first layer is a widepolyethylene sheei ihatyou spread over theabdominal v iscera andcarefully tuck between thebowel and the abdominalwal l . Pui two surgjcaitowels over i t , p lacedsecurely beneath iheabdominal wal l on al lsrdes. This is the middlerayer ot the sandwich afdiis pufpose is to absorb
contain and protect the uo*"r *t*, t"iplilfiI--inJlfii
4 The croih toporoiomy g
Now, Place iwo silicone drarns on
the towels and br ing them oui
ihrough separate stab incisions
Cover the wound with a wide sienle
polyest€r drape, comPleting .lheupper layer o{ lhe sandwrcn'
Connect the suction tubing to a Y_
connector, then to a suclion source,
Occasionally we sull use a soti
empty intravenous f luid bag fof
iemporary abdominal closure The
bag is unfolded bY
cut i ing the seam and
then ster i l ized. We
suiure il to the skin along
the edge of the wound
with a running heavy
monofi lamenl sulufe,preserving the fascia lor
the definitive closufe
This technique is more
tima-consuming than ihevacuum pack but provdes
inexpensive, alraumatic
containment of the abd_
There isn t much we can tell you thal you don'l akeady know about
definitive closure of a midline lapatotomy incision The correct technque
Jrut ino Uiq oire" c 'ote rog€thFr, withoLi tersron We do a tass closure
'" , i i "v""," , i " ns . . - i19 heavy mo'rof i '?mert sutJ 'F' beoirnrrg ai both
""a" "t tn" i""i"i." and working toward the middle The cardinal sin s
"i"""* ""0", tension lf you siruggle lo contain bulging or distended
uo*"t, ,f'" outi"n, "iff
f" ;uch betler off with temporary closure l/lake a
4 rorrrn,*^._ ,* 44 8 Crol t oI i ,outo Surger/
iihtil*r,",31 il'r".ffi :,T:iT,,H,",:".""","rx-q;
T H E K E Y P O I N T S
) Enter ihe belJy wjth thfee sweeps ofi) siay away from ord
"""r".
'--- '' 'n" nn^ "nd
one educated finger
) Evisceraie ihe boweteariy.
) In blunt trauma, begin with empirical packrng.) In penehating trauma, eviscerate and) Exprore rhe supram""""",::*
,;,;
t" t"r the bleede'
) Keepretroperitone",",r,:.;;,.,r;":::;J-*-.
) An expanding ceniral hemaioma does
) Feer rhe muscres o,,r" ;";";;*, ,:";.
t""""
) Do a rjght-sided medial visceral rotatjon in three stages.) The Caiiell_Braasch maneuveri from CE) conian and prorec,,,," ;;:; ;; ;;,:";ffi_:"_"
ChaPter 5
Fixins Tubes:The Hollow Organs
And if anvthing lhal I saV should bear lhe apPeanncP of
)-",'"r17ii'rt?r*u, let ie publicly cont'ess that Ihi5 book
li"i""riti, 1r"* a sonooful coniemPlalion of the 'nonv''rigiroi
,nort ,nirn I ha;e myself conmitted
- Harold Burlows, CBE
Erlalls o/S /ge'Y' 2nd ldition'
London' Bailliere' Tindall arld Cox' 1925
One of the mosi remarkabLe 'corrective experiences' in surglcal
training comes during the morbidity and mortality conference' as you
relucta'ntlv rise io explain to an unsympaihetic audience how you
overlook;d that bullet hole in the duodenum From our own expenencer no
Jrir"" "or"a"
p"tti""r"rly convincing' so never get loo complacent wth
ihe injured gut lt often hides some nasty traps'
Immediate concerns
Your l i 's 'pr 'o ' i ies are Io conl ro lo leed'ng and conla i l sp l l lage o ' '1 lest 'na l
-"*t ",
,i:"" ff'" **e' does 1oi bleed mJcn bJ'the mesertery does
lf the bleeding vessel has
retracted beiween lhe
leaves of the mesentery'
all you can see is an
expanding mesentenchemaioma. Raiher thanwaste irme ttyrng Io
ideni i fy the bleeder,simply apply Pressure Io
lhe area, We usually use
either the assistant s
hand or long sPonge_
holding {orceps aPpl leo
TOP KNIfE The Art 8 Crofi of Trourno Surgery
to ihe injured mesenteric segment, squeezing it gently between the ringed
When the bleeding lacefation is close to the root of the mesenterybeware of a irap. Never junrp in and bllndly clamp or oversew ihe bleederbecause you rnay destroy a superiof mesenteric vesselor one of its maiorbranches. A classic example is blunt avulsion of a proxinral branch of iheSMV which can be the result ol a deceleration injury or iatrogenic iraumalrom puiling hard on the mobilized right colon. you encoufter bnsk venousbleeding or a rapidly expanding hemaloma at the base of the mesenteryBlind clamping may result in a transected and ligated SIVV
The correct approach is toinsinuate your hand behird themesentery and pinch thebleeding area beiween thumband forefinger. This controls thebleedrng. Now, carefully operthe serosa, precisely define theinjury and fix it. With a bllntavulsron injury, you will have tof ix a side-hole in the SMV
Use soft bow6l clamps tocontrol spillage from stomach orbowel perforations. A hole in thestonrach or bowel can also betemporarily whip-stltched wlthseveral bjg bites that will controlmucosal bleeding. Pack abladder perforation f or lempof ary
Bleeding from the root of the mesentery is a trap
Missed injuries
Pay special atiention to five locaiions where
often miss a hole ln the gu:
5 Fll ng TLJbes: The Holow o'nt* H
cursory insPection will
tuophagogast c Lbament orTleits
Mrssing a gastr;c Perfora'ior has me 'nosl immeoiate coiseorerces'
ci""" rL". qtomarh is tne 'nost vascLlar organ ol tne gLlt -lssing a I'ole
i""""- t" , * i f ' be bacl in l l^e oR wthin a coLple o{ hours rac'ng a
Hil;;" ;" ; "
*atermelon filled with blood and clois Much like a
;i;"J;; ;;; ;";" the mosi problematic and easilv missed sastdc
iniuries are located high on the lesser curve or in ihe posterior wall near
111'; ;il ;;;t;" t"h" s'"ut"' ""u' or the stomach bv dividins the
o""t."ofi. o."*rt. Ope; the lesser sac widely and lifi ihe greater curve
;p to have a good look at the entire Posierior wall'
TOP KNIFE The Ari & Croft of Troumo Surgery
ln addition to a very meiiculous exploration routine (Chapter 4), twosaleguards help you to avoid missing a hidden jnjury to the Gl ?aci:
1. Reconstruct the trajectory of the wounding agent. Thrs tmjectory mustoe trnear and make sense. Bultets and knife btades do noi disappearinio thin air on/y to feappear out of nowhere in another part of theabdomen. You musl be able to connect the dots. When the trajectoryoi ihe wounding missile is unclear or does not make sense, youprobably are missrng an injury.
2. Be concerned when f inding an odd nlnrber of holes in ihe gut.Tangeni ial wounds certainly occur, and occasional ly a mis; i lepedorates only one wall, but this is uncommon. Therefore, an oddn!mber of holes should prompi you to re-evaluate the area in searchol a missed pedoraiion. The oniy exception is a single stab wound tothe anterior gastnc wa I, which is relatively comrnon.
When examining the colon, it pays to be relen|essly paranoid. Becausenruch of the colon is reiroperitoneal or covered with omentum andpericolic fat, missing a small colonic perforaiion is easier than yoLr ihiik.Do not leave any subserosal hematoma on ihe colon, no maiier how smaliand rnnocent-looking, without unroofing it by opening the overlyingperitoneunr. Very often, this seemingly lnnocent superficial siaining hidesa perforation. lf the wo!nding agent passed close to the right or left coton,mobilize it and look carefully at ihe posterior wat.
The ureter, 1oo, cafries a high rate of missed ifjuries. Whenever a bulleiirajeciory passes afywhere near a ureier, nrobilize the re evani side of thecolon, identify the ureter, and irace ii proximally and drstally io ensure it isintact. Iniravenous methylene blue dye helps identify a ureteral injury thatrs not rmmed aiely obvlous.
Bullet traiectories are linear and must make sense
5 Fr, lng Tubes The Holow Orgo's n
Choosing a repail technique
Now that yoJ are 'eaoy to repair Ihe ;nlutle5 choose an ooeralive prof e
r:r*il :"1i1*:::':il"d1," 3:l ::1"x1;;,:';li J:'l ::ffilll';"::,*:;' ;r;:* ru :x'i:!J:,'il""i:'" ":"'il;"' :i ;"'i;;"-;;'iai";;i;o;-"sorLi'ons YoL don\ l've Io do a ro-mal 'esecton
and reconstruction to prevent spillage'
Damage control fot the bowel
The most €xpeditious way to prevent spillage {rom a eeforillon-(11-d-l:
uchi"ve lemostusjs at tne same time) is to rapidly *t*t ]:,i:'iS-:^:19-:' '
t"a' -taP el Whel operat ng,ayer contin,oLs stilcl' or' less common y a lr'.,
;';;;;; ;;",;;.;''however, there are ofte" ll|]*"1-1""^llllillff i .;:1."ti;; ;; ard the parent's phvs'orosv, ard -assourarFd
i": i" il"""i",r.- il ro oarieri,y p€rcn up.hor" i-,::]ill"]lljllt",ile 'e ar€ tnF most common'Yq;:c^ ard ef€cllvF spi"age conLrol so uton t
used opiions:
a Bowel interruptlon oY
stapling across wfln a
linear siapler Pfoxmal ano
distal to the Perforatedsegment, or ligating ihe
bowel using a cotion laPe
wiihout reseci|ona Bowel resection without
anasiomosis is a good
solution if ihe injury involvesa bleeding mesentery ll
you have to resect a
considerable lengih ol
bowel in a Patrenl /n
exfremis, Your qulcKesl
option is to sequentially fire
a series of linear cuttingsiaPLers with vascular
E ,o, *"n, rn" o,t & crcrft oi Troumo suroerv
loads across the mesentery close io the bowel wall. lf residual oozingf.o- rhe craole. hae oersists, raordly underrun,t wrtr a cont,r-ouimonot tamenl stilch
a Stapled partial gastlc resection without reconstruction for adevastairng gastric inlury is a third opiion. This stapted emergefcygastreciomy is a staged procedure - wiih resection during the initialbail oli laparotomy and reconstruciion at laier reoperation.
During a bail oui laparotomy, avoid external stomas, if possib/e. Theabdominal wall swel/s up postoperatively, and ihe stoma often retracts orbecomes ischemic. By cfeatiig a stoma you afe also makifg definiiiveabdominal closure more difficuli.
Ulological damage control
Ur ne spillage into ihe periioneal cav ty caffies a much lower short_termnsk of infection than intesiinal spillage. If time is critical and you need toget out of the abdomen, tle off a transected ureter and plan apercutaneous nephrostomy if the patjent survives. lf you have no time tofepair an injured bladder, just pack ii and rety on a Fotey catheter fordrarnage - a suboptirnal bul accepiable solution if extreme circu..stances.
It you have a few minuies, intubate the tnjured or transected ureterproximally using any available ihin caiheter (such as a pediatric feedingtube). Secure ihe ureter to ihis drajn with a tie and exierlorize ihe drai;through the abdominal wall. Leave the distal ureter alone. It will not leak.
The biggest m stake yo! can make with a ureteral injury ls io mobilizeand dissect oui the ureter in an attempi to better define the injury. you willonly jeopardize the blood suppty of the njured ureter and makesubsequefi reconstructron more difficult. lf you afe noi going to repair it,lust divert the urine and don t fjddle with the Lrreter.
You can conhol spillage ffom the injured gut without resection
5 Fixing Tubes:The Hollow Orgons f
Close a bladder iniury with a quick running stitch lt doesn't have to be
" r."'"ni"1l","a
"t.a-*pair if you are pressed {or time: a single layer wrll
^^ ' " ;." Wfit" a'wavs tne besl oot;on' sLture closure iay loi be
L"j o," r"'ir u u"'v ,"tn" delecl On rhose'are oLcasions vou 'nav eecr
,ffi.ri lt *tr#r"J roih ureters and iightlv packing the open bladder
{or hemosiasis
Def inifive lePair techniques
The stofiach arrd distal esophagr'rs
Reoair qaslt'c perforations Js:ng a 5ut'i'e or slaoler' On ra"e occa"'ons
massrve o;skJcl:on ol the stomauh rcqJires d panial gasirecto-y
The cardia is ihe pari of ihe stomach most difficult to visualize and
repair, especially in obese patients Approach these problematrc Inlurles
svstemarrcdly. Frrs ' , opirmire your exposu-e l - lh6 ncison ene'rdrng as
f j , , " " .
o" i" iUf"f ," r" ' r ' -Fi ;ac1or do ng urelJl work? SnoJrd vouinseri
." ,lp* i""l i"u*t,irr lslhe patient iilted head uP? Nen' mobilize the EG
jlnction as il You wete gorng
to do a vagotomy We do
realize this is rapidlY becoming
a losi ad, but in this situation ii
is the key maneuver' Take
down the lef t i r iangular
ligameni oJ the liver, told uP
the left laieral lob6, oPen the
posterior Peritoneum overlYrng
the esophagus along the'white l lne, ' and encircle the
esophagus wlth Your nnger
This gives you good access Io
the injuri,.
i-,"i*n" it "n "t""tt.nt
damage control option for the ureter
TOP KNIFE ]he Art & Croft of Troumo Surgery
Someijmes you have to develop a creative technical solution for aproximaJ gastric injury. Jf you cannot roli ihe distal esophagus and cardraio expose the injLrry because it is posterior, open the anterior wall of thestomach longitudinally near ihe cardia, ihen jderiify and repair ihe hjghpostenor perforation from within ih€ siomach.
Injur ies to the disial (abdominat) esophagus require the samemobilization of the EG junction and care{u definition ofthe lnjury.lfyou areoperating jn damage control mode and there is no trme for meiicuousdissection ard repair, insert a large suctior drain into ihe open esophagusand bring it out thfough the abdomifal wall, creating a controlled listu a.This effect ive temporary sout ion eaves ihe door open for later
We repair a slmple laceration of the distal esophagus using a singlelayer suture after careful debridemeni of the pedoration, and we alwaysdrain the area. You can use the cardia of the sromacn as a serosat palch(Thals paich) to buttress the repair. Very rarely, you wlll encolnter adevastaiing lnjury that has destroyed the EG juncrion and requiresresection of the distal esophagus and proximal stomach - a proxrmalgastreciomy. These patients typically have multiple assocrated injuries andneed a rapid bail oui solution. Transeci ihe siomach across the body usinga lrnear stapler, preservlng as much drstal stomach as posslble. Lift iheprox mal part of the inlured stomach and mob lize lt along the lesser andgrearer curves atl the way up to ihe esophagus. Divide the nrobillzedesophagus as low as possjbie and remove ihe destroyed part of iheproximal stomach. Secure the open esophageal stump to the diaphragmto prevent retraction into the chest, and insert a closed suclion drain iniothe lumen. This danrage conlrol solution leaves the pateni with a stapleddistal gasiric remnant and a dfained open esophageal stump.
Access proximal gashic injuries by mobilizing the EG iunction
5 Flxlng TLJbesr The Holow O'gt* E|
The small bowel
Before repairing a hole in the small boweL make sure the edges ol lhe
p"*or"tion ur" hJafthy and oozing nicely- If ihe bowel wall is bluish or
iraumatizeo, debride it. This is especially important wiih high-velocty
"rnlnoi*ou"a" *1"t" tissue damage around the hole can be extensive
Lornrnon ""n""
dictates repair oJ bowel perforations in a transverse
o--ri""i"tl.n, *ti'"t tf,"" fongitudlnally, io avoid narrowing the lumen Joining
".L"".iia". i"'o
" "nsle-'acerar'or * rl save you lrme a,rd Lrouore Ho es
ln'*" n'","t"n" bo,Jer or the bowe can oe t ' ic\y 'o f i^ CatefJrly
mobilize the adiacent mesentery to see ihe entire defect clearly before you
begin sewing.
Expect some difficulty wiih iniudes io the most proximal jejunal segment
**'iJii" o"t"" "f r'eitz T;e kev is io mobilize ihe ligament and free
if'"-frorinra"ppnrrrl Rarely' you may have io do a complete Cattell'
era.""L man"uuel. (Chapter 4) to get to the foudh portion ol the
duodenum and iis transitlon inlo the proximaljejunum
Repai ' Ihe bowel Lsi ,rg ILe tFchnroLre yoL a e -osl co- lortable wi 'h '
O_e ol u- p 'e{ers to use o si_g e taye'corr i ruous st tc,r ror mosl Gl sul ' r 'e
lines (including the stomach)' while the other prefers a double layer
techn'qLe. Bot,l a'p sale 'r perfo'meo corr"uJv -esLhng i,r a.l irvered
*el l .vasculanzeo sLLUre ire wi l l^oLl -ension l f yoL n^us' do a bowe'
fesection, preserve bowel length and minimize the number of sulure lLnes
Tne lpwe'suiLre l ines you creale rhe befte '
Colon tt til rcctum
lf vou can close the 6olon Lacetaiion with a simple sr'riure _ jusl do ii No
amo;nt of peitoneal contamination should dissuade you ffom doLng a
straightfoMard prinrary repair' Blt what if ihe injured colonlc segment
mLrst be resecied?
Preserue bowel lenglh and keep suture lines to a minimum
For a right-sided or transverse coton injury, the answer is simpte: do aright coiectomy afd join the terminal ileum to the iransverse colon. Thissate anastomosis is unlikely to cause you gref. The question becomesmore interesiing (and more controversial) in the left colon. your options areio do a colocolostomy or to close the drstal colon as a Harlman,s pouch,bringing out the proximal segment as a colostomy. An extended righicolectomy and rleocolostomy in ihe descending color is a va id alternative,bul t is se,dom Lsed in -raL-a becaJse I is t tme-consum n9.
In recent years, resecting and joining ihe unprepared left co/on hasbecome a iashionable opiion. I\,4any surgeons ialk about ii;fewer do it, andsome have had occasion to regrei it. We belong to the lafier group. Ourpreference for extensive Ieft colon damage is resection and colostomy. Wemay occasionally do a co ocolostomy for an isolated colon injury in ayoungstable paiieni who can toleraie a ieak. We would not even contemo aie lti , r a oal,e,r t who ha- sJsr€r leo massive prys otogiua rrsJl t , rs eldel v dndf.ai , . of Lnde.went oihe. -epairs t l -at mav lea\. A case in ponl i ; theexp osive combination of left colon and left kidney repairc, where a leakfrom one suture line puts the olher repair ln immediate jeopardy.
1 .
TOP KNITE The Ad & Croft oi Troumo SLrrgery
Try to identify ihe injury using a rigid procioscope. Repair it only if tt iseasrly accesstble. lf you suspeci a rectal rnjury but canrot prove it,perlorm an enrpirical fecal diversion. A temporary colostomy is anuisancei a missed lower rectal injury can be iatat.Do a slgmoid loop colostomy. When properly construcied at skin-level, ii is totaly diverilng. Some surgeons use a linear stapler to ctosethe coion immediately distaito the colostomy, oryou can sjrnply iie thesigmoid wiih a heavy polypropylene suture and anchor the stitch toihe fascia.
lMany surgeons talk about colocolostomy for lrauma; fewer do it
Deal with an niury to the intrapeftoneal rectum exactly as you wouldhandle a peforaied lef t colon. Management oJ trauma to theextfaperilonea recium used io be an elaborate ritual ihat lnclLrded iotaldiversion, repair of the injury, washout of the distat reciat stump, and pre-sacral drainage. The current approach is much slmpler:
2.
5 Fjxlng TLrbes: Ihe Holow Orgo"s g
don't insert a Presacral draln'
Bladder and wetet inities
Here, we can summarize our advice in a single word: DON'TL When
oos"ifL. ast u urofogi"t to perform definiiive repair of an injured bladder
lr ureie. The ,-rrotogist las a beiter grasp of the various technical opiions
""J f]o* to
"loo*in" fest one for a specific situation Furthermote' the
ufolooist will also manage any complicaiions and underiake long'term
folrowl-rp. Wheneve. pocsibe. we aol^ere Io tnis onnc pre even wrlh
straiohtlo'ward illtapethoneal badde' njuries li a Jto'og st is nol
avail;ble, damage conirol is always a sound option
3, Don'i irrigale the rectal stump
Neither is necessary'
T H E K E Y P O I N T S
) Bleeding from the root of the mesentefy is a trap
) Bullet traiectories are linear and must make sense
) You can control spillage ffom ihe irjured gui wilhoui reseciion
> Drainage is an excellent damage conttol oplion for the ureier'
) Access proximal gastric injuries by mobilizing the EG junctron'
) Preserve bowel length and keep suture lines lo a minimum'
> Many surgeons ialk about colocolostomy for trauma; fewer do it'
) Dlved the fecal stteam away from extfaperitoneal rectal injuries'
6IJ tn"-"* tn" t"*t "tr""t
away from extrape toneal recial inluries
P ,o, *n,rr rn. on & cfofr of Troumo sursery
a.npoa,tt aa$ "49{ J
* ^"- ^B carry'u'67 -
- r^'v')' /1,-0 \r,
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?'.ct<1 t{*: o .L\}-,**G4-.
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&r'- o- t,.t".tzl-}\ g,tt 4'z r*7*l< -&,t.- s-x-uJ^rr^ d r-*.4
V
(1fnt
Chapter 6
The Iniured Liver: Ninja Master
No battle plafl s roioes the first fiaefiill tes oI cofttttct Toith the eflefi!'
- Field Marshal Helmuth von Moltke
l{ trauma surgery is a contact spori, lhe badly iniuted liver is the Ninja
Master: a vicious, cunning and lethal adversafy When you come lace_lo_
face with a massively bleedlng llver' gLance ai ihe OR clock and then atthe
anesthesiology team frantically pouring blood products into a raprd
;nt,rsion d"UJe you huve a window of aboul 20 minutes and roughly 8-10
units of bLood io slop the bleedlng That's all Take much longer' lose more
i i"oO, ot." t" an error ln iudgrient or iechnique' and ihe Ninja N4aster
wins again
Obtain temporary control of bleeding
Once inside the abdomen, quickly look al the undersurface of th€ lver
and swipe your hand over ihe superior hepaiic sLldace on boih sides ol
ihe falciiorm llgameni lflhete ls a signiflcant liver injury' you willsee or leel
ii. At ihis point ii is tempting to start fixing the iniury - don tl An obvious
lwer injury is often jusl one of several sources of hemorrhage and noi
necessarily the mosi important one Resist your natural tendency to zoom
ln on the bleeding liver as yout pdme iarget befofe rapidly assessing the
rest of the abdomen
Your fLrst priority wiih a bleeding liler is to stop ihe bleeding The three
ootions {of ter.porary control are manual compression' temporary
packing, and ihe Pringle maneuver Each option is useful for specifrc
operative cLrcumslances
TOP KNIFE The Art & Croft of TroLrmo Surgery
a Have your asslstant reach across ihe operaUng ta6te and nanualycompress the injured lobe behir'een the palms of both hands, anexcerrent way to gajn temporary conlrol of a badly shaiiered lobe. lialso allows you to begin hepatic mobilization around the compressinghands.
) Tenporaty packing ts a good rnriral move, especrally tf you are notsure if the liver is the major source of bteedtng. Rapidty compress thelnjufed lobe in a sandwrch of laparotomy packs placed above andbelow it (Chapter 2). You wit return shorily for a ctoser took anddef initive hemostasis.
a l i the iver is bleedingdespite temporary packing,consider inflow occlusionof ihe portal triad, the well-known Pringle maneuver.Poke a ho/e in afr avasculafport ion of the lesseromentum to ihe left of theporial t f iad, inseri aneducated f tnger into theesser sac, and gently pinchthe portal tlad betweenth!mb and Jorefinger. lf themaneuver is working andbleedrng stops, replaceyour ingers with a largeaortc vascuar clamp, a Rummet tourniquet, or ( i f none of these simmediaiely available) a soft non-crushing bowel clamp. Note ihetme. Nobody knows for sure how lofg the porial triad of a traumapaiient can remain clamped before ischemic damage occurs, but youhave at least 30-45 mlnutes, probably more. Rer.ove ihe clamp asquickly as you can.
Sometimes your temporary hemostaiic maneuver fails and the bleedingcontinues. Barring a techncal error (such as neffective packing or an
6Ihe lnjured Lver r inl" v" ' t" ' I l
incorrectly performed Prlngle maneuver), there are ihree posslbe reasons
Jor ongoing hemorfhage:
a Packs oo 1ol conlrol ane'al b eeoilg You reeo 'ntlow occlus:on
a lf the bleeding lrom lhe liver looks aderial despite inilow occlusron'
ihe hepaiic ;ery may have an anomalous origin Try supracellac
aodic clamPinga lf dark blood i; gushing from the deep recesses behind ihe liver' you
are aeatlng *iih'a rei;hepatic venous injury lf you aren'i sufe' ask
ilJ "n""tf'"""iofosi"t
to momentatily disconnect the paiient from ih€
1 vent lalo- l{ tne b,eeoing abares' your s'rspicron is uonf'r ed and yoJ
- ,no "or.
panent are i; dt;FlroLb'€ lncise lhe lalc;for- ligameni'
g"-' i, *i ' i "
a"-p ald oush s"rirv Posr"rio' ' ' i l : t: ' ' i , ,:1 *::
ilts tne rv"r ba'kward end may lemporarily "ortrolil'e bleedlng wn |e
yol.r colsioer your oprio,rs and orgarrTe yoJr attaLk
Mobilize the iniured lobeUnless ihe hepatic
laceraiion is Peripheral and
anterior, you cannot assess or
fepair it until You have
delivered the injured lobe to
the midline, much like the
injured spleen. To mobilize the
left lobe, divide the iaLciformligameni between clamPs and
then release rt all the way uPto ihe diaPhragm, exposLng
the areolar tissue of ihe bare
area of the liver Then divide
the left triangular ligamentand conUnue the incision inio
the anterior and Posteriorcoronary ligamenis Beware
of the Phrenic vein that is
very close to your scissors
Controlthe liver temporarily uging hand, pack' or clamp
TOP KNIFE The Arl & Croft ofTroumo Surgery
S r.ilarly, puttlng your handbehrnd the r ight iobe androtating jt medialjy streichesthe right triangular ligamentand allows you to divide itsafely. Cont inue the mobi lizat iof by releasing theanter or corofary l igament(taking care not to inlure thelver capsule or the r ightdraphragm) and then theposterior coronary ligameni.Your goal is to deliver theeftire rrghi lobe io the midline.
Be liberalwith your mobilization, but atso be carefuli the hepatic vernsand IVC are wa,t .rg tor a carele5s move, ano tre smal, acce;so-y ve 1seniering the IVC below the right hepatic vein are easrly avulsed with a
Mobilize the injured lobe to deal with it face-to-face
Here, a deadly pitfall awaiis you. N4assive gushes of dark blood comrngthrough a deep iaceraton n the liver or from behind it ik_"ly represeni annjury to ihe retrohepatic veins. Mobiizing the liver in ihis situation is arecipe for disaster You wil lose containment, and the patient wilexsanguinate from uncontrolled venous hemorrhage before you evenrealize your mistake. So, ifyou have any suspicion of a retrohepatic venousinjury, don t mobilize the liver
Small problem or BIG TROUBLE?
Nowhere s the disl inct ion between smal l probtems and Btc TROUBLE(Chapter 2) more usefulthaf in hepatic irauma. Small problems are liverInlunes that you can fix wiih a direct, srmple maneuver: the diathermy, aliver stiich, or a loca hemostatic agent. The injury is accessible and bLoodloss is noi dramatic. Most liver injuries belong in this category.
6 rhe lntured Lrver' Ninlo Moster g
BIG TROUBLE is a high-gtade iniury with massive blood loss' and you
*"'i" it.i"""ia*g"t i lJsing your patient The decision whether lhe
ii,y i" " "."rr
ptoSL. or BIG TROUBLE is the kev stategic decision in
hepatrc lrauma
Deal with low_grade injuries directly lf a superficia laceration is not
of"eJlnq, f"au" it lrone l{ ihere is slow oozing, direct pressure for a lew
t""i."".U"" stops the bleeding Your hemostatic effods should be
proportionalto the magnitude of the injury (Chapier 2)
With deePer laceraiions'
have your assistant Pinchihe edges of the laceration,
turn the cautery to KILL,
and blast the faw bleeding
sudace, focusing on the
disruPied edges of the
hepaiic caPsule APP|Y ihe
cautery to a metal sucker
l ip to achieve a wider
effect. Use an Argon Beam
Coagulaior, i{ available, to
thoroughlY barbeque ihe
raw surface. Use a toplcal
hemostailc agent You are
Jamiliar with from electve
surgery. ,- tJ-' t
Nevi, consrder hepdlorrhap'ly For yoLr sJlLres Io holo you need a
,"""onufty int""t ""p*te
ani a more or less Linear lacefalion that can be
"_o-otlt"t"a sidelo_side We typlcally suiure hepatic laceraiions with 0
.iiornl" on "
utrnt-iip Lurge needle, cfeatlng a row of horizonial maitress
sutures. The chromic suture slides through the hepatlc parenchyma' ano
ihe laroe curved needle enables you to obtain a good bite ot irssue
TOP KNTFE The Ari & Croft of Troumo Surgery
, Wrrh Blc TROUBLE, you are ope.ar ing . . l damage controt rnode. Ihe
Key lo sLccess ts yorr ability -o srop the ooFraltol a1o o.ga'lize yoLlattack on the injury rather than get canied away and attempi h;rorcmaneuvers on an exsanguinating patient {Chapter 2). The rest of thigchapter describes ihe techniques we have found most lseful in baifleswilh hepatic Blc TROUBLE.
"Packing plus,,
Packing is the technique you will use most commonJy for a high-grade|ver injury. lf you have packed the liver early as a temporary hemostaticmaneuver and the bleeding has stopped, you have achieved homostasis.Removing packs at this point is a mistake.
When you cannot be sure thai you have complete hemostasis wthpacking, especially jf you had to remove the packs for bleeding bui did noifind any discrete arte al bleedefs, considet packing p/us - imrnediatepostoperative angiography with selective embolizalion as a hemostaticadjunct. Thjs is a risky undertaking in a critical patient and involvesmobilizing fesources thai may not be avajlable to you. However, if it is arealistc option ai your instltution, selective embolization of arterial bleedersdeep within the liver can be lfesaving. lf your OR has rntraoperativeangiographic capabilities, the decision is easy, and embotization ispossibie withoui moving the paiient. lt is crucial io make the decision early.Decide that you are going fof angiography while you ar6 repacking theliver, noi thfee hourc laler.
Keep in mind that angiographjc emboljzation is an adlunci to effeciivepacking, not a substitute for sloppy hemostasis. lf you didn t pack the ljvefproperly, angiogfaphic embolization will not save your patient.
Decide if you sre dealing with a small problem or BIG TROUBLE
Consider angiographic embolization as an adjunct to packing
6 rhe Injured Live( Ninjo Moster
o c \ ' t t ' /n" ' ' ; c ' ^ b l " ' t ' t i1
Deep liver sutures L+7 ;'f*J(r. '
Deep livel sulures have a bad reputation They cause necrosis of tissue
lnclorpJratea in the stitch, predisposing to inlection or 'liver {ever'from
;;;;ir*l ntec,iot Do,.t lel rh s bdd teoutalior rob vol o{ an
#:# ;;p- " ,",'
bahre witl^ tnp \rnia Master' espec:ary i{ vou don I
;;".;;;;*";" wlth the injured liver or need a rapid bail oui
""ili'"". O f,* O"t'*, *ith some hepatic necrosis is far betier ihan a dead
Wnen olac nq deep hve- "LLures you aust nave a,l i,rlacl caosule to
hol em Wh; ryirg righter ver)/ carelully as r vou are tyr'lg a sJrure
ir,-r,*gi oft,go""i [utter' Look for blanching of the liver parenchyrna
u."",* ,n. =ut,-r" . w\ ic l 's iqnf:es the sulLrP is t :qhl Cl"oose a suru'e
r""a"r"t ' "" Ihat is best lof lhe spec:fc anatomiu c 'rcJmstdnces:
il;ffi i;' so,neti,nes uerti"atl mattress' a {isufe of B' or a simple-
iffii'""i'tnt""gf', with or wlthoui an omental buttfess Regardless or
"o* il** configuration, io obtain a good purchase of hepatic tissue'
in'" n""J" .""t u,iu"t" tove perpendicular to the surface of lhe lrver and
A irap with deep liver sulures is early posioperative bleeding As the
rnureo l ,ver swel ls the s ' i lures mdy cJt lh 'oLgh the ede'natoJs
pu,"n"t'yt" *'tn 'o"" ot Lne hemoslatic ef{ecl and rebleedilq'
Hepatotomy with selective vascular ligation
This is a useful lechnique to contfol bleeding lrom deep in the lrvet'
especially if you are an experienced surgeon When you s€e anenal
f'"L.rrf'"g" ".*tn
ft.. a deep laceraiion' rather than irying to close a
;; ; ; ' ; "" ;*" oplen i t w'der ard so in l^o nrsLirorrFenddena e"al
iiJo"'" l" """'"o,*
go to tne heart ot danger lo find sarerv
Deep liver sutures are not a crime
E roa ̂ ",rr rn. on & croft oi Troumo suroerv
With a pringle maneuver inplace, incise ihe hepatic capsutewfh the cautery io extend theIacerat ion, Then, open theparenchyma In the direction ofthe injury using fingerffaciure (ora blunt metal instrLrment). As yougo deeper into the liver, gentiyrnsert a pair of narrow Deaverrelractors tnto ihe Jaceration tofacilitate exposure. L,sing thistechnique, the liver parcnchymaorsrntegrates beh,veen yourfingers while ihe ductalstructures remain iniact and carlbe controlled (with ligatufes,sutures or rnetal hemostaticclips) and divided, enabJing youto widen the gap a1o go daeper. We preler to 5uurer.gate all sign:f.caniorFeders beL€Lse sLtu.er grures do nor shp wher you conr,nue wor^rngIn rne area. t t you use ]relal ne-roslal ,c c, ips. apoty rwo ul ,ps lo eachd uctal
, structu re (double ctipping) to pfevenr stipping. Occasionaly, an
rnlured targe intralobar vein wi l l require laiefal repair using S:Oporypropylene.
Hepaloromy wJr selec-ive vascu'ar ligatiol is a near uoncepr. b i tls
lfelrc.alron in the real worid is tess straightforward than the preceding
description leads you to be/jeve. lt invotves significant ongoing btooa toss]
: l l-:::*-nn ,a-,oeenc ,rrLrrro a malo. reparcduct o. h la. vesser. LJce ir onty afler you havF o.ga'rizeo yoLr ailact andwnen rne pdnent c esLscitated and ca'r io,erate adoilior.t olood loss. lfyou don t have -ucn expef ierce wirh neparic trauma, deep r ivFr sutJrescan Ee a s mpter alternative,
Hepatotomy with selective ligation is easier said than done
6 The Inlured U'er: Ninio Mo'ter g
The viable omental Pe'licle
On comple+lon ol ilnger f-acture hePatotomy and seleclve vascula'
r;oJln. uo, are tefr w-ith a considerable dead space Fillng it wrth
"il""irtti* ^ o*o idea. The same applies ro a deep livet suture where
"'"""ili..""",". *" r'relp you achieve hemostasrs ln fact when dealing
*ii 'i" t*,"a ruer, rh" greate- omentum rs one or vour best {riends
lf voJ have time, mobrize rhe greater omentum ofl Ine [ansverse colon
aoniiie tuoauss tine Select a healthy chunk, typically lrom the righi side'
and-separate it by dividing the omentum longitudinally toward the greater
curve of the stomach.Swing the mobilizedtongue of omenlum uP
into ihe iniured livet
and fix ii to ihe Lrver
capsule with sevefal
loose stitches. Another
option is slufling the
omental tongue iightlylnto the laceration,{illing lhe space, andthen approximaiing the
laceration loosely wlth
several liver stiiches
over the omental PackSome surgeons use
omentum {or Packing{rom within insiead of
laparoiomy Pads orgauze rolls.
Fill large parenchymal defecb with omentum
IOP KNIFE The Ad & Croft of Troumo Surgery
Balloon tamponade
When dealing with at h r o u g h - a n d . i h r o u g h(transfixing) lver injury,whrch rnay occasionallyInvoive both lobes,renrember the option ofbailoon tamponade - anIngenrous and easysolution to a very badproblem. The alternairveis erlensjve iractotomyto achieve directhemostasis.
lf the tract is wide (2cm in diameter or more), we use a Blakemore tube.Insed the iube into the tract so that the gastric balloon, inflated outside theexit wound from the liver, will serve as an anchor to prevent drslodoementof l le ruoe. Then genry i r , latF rhe esool^ageal oaloo,r r . the tai t u-r i lbleeding stops.
lf the tract is ioo narrow or ioo short for a Blakemore tube, we improvisea balloon lrom a .ed .Lbber carheter and a pe'rrose drain. T,e ofl onpend ofthe drain with two heavy sitk ties. Tie the other end afound ihe catheter.creaiing a sausage-shaped bal/oon. Check the balloon for leaks bv iniectinocal ine r l rough the reo .Lbber calherer ard La-pirg f . ne'aevce, iworking, insert the balloon into the lract and brjng the oiher end of thecatheter out through a stab rncision in the abdominal wall, as if it were adrain. Inflate the balloon and watch bleeding stop as if by magic. Secure thered rubbef catheier io the skin and make sure the end is ciamped.
You can safely begin removing the balloon at ihe bedside after 24-4ghours. Firsi deflate the device, but keep ii jn place for 6-8 hours. lf ihereis no cl in icalevidence of bleeding, pul l the bal loon oui l ike you would afvolher drai f .
Balloon tamponade is a cool solution for a bad problem
6 The Lniured Liver: Ninjo Mosler
Resectional debridement
When a subslaniial part of the hepatic lobe is desiroyed and bleeding
orofusely, ihe most expedient opiion is reseclional debridemeni Have your
^"ai"t"ni n "nuully "otpress
lhe non'injured liver parenchyma around the
area you wish to resect lf the lobe ls properly mobilized' o{ien your
assiint wiLl be able to completely encircle ihe injured part' minimizing
blood loss whlLe you do the reseclon
Turn the cautery lo maximum and use it to de{ine a line of resectlon thai
is immediately outside the injured area in healthy hepatic tissue Always
resect imrneiiately outside the injured area where the vessels ate iniaci
and have 1or rer;credi "_j.=-jj!I:El_!jg]
rh,s is ,he \ev
maneuver of resect onal debndemenl
Perform finger fracture (ihe 'pinched corn bread' maneuver) and
selective ligati;n along your chosen !ine of resection The slmplest
example foiuse of this technique is resection o{ the left lateraL lobe along
a llne imnrediately to the left of the lalciform ligament Some surgeons Llse
a linear cuiting stapler wiih a vascular staple load io faciliiate ih s non_
anatomic hePatic resection
Much like hepatotomy and seleclive vascular ligatlon' reseciional
debridement takes iime and involves conslderable blood loss Don'l
aitempi it in a Patient rapidly dving on the operatlng table Organ ze youf
aliack and resuscitaie ihe patient before you begrn
Othel techniques
The traLrma literatrrre is repleie with many techniques that resourcelul
suroeons have developed ior dealing wilh bad liver injuries One example
is tie absorbable mesh wrap. By snugly Jitting a 'pita of absorbable mesh
around a shattered obe, ihe advocaies of this technique achieve elfectlve
iamponade, avoid ng lhe need for packing We find this technrque
c!mbersorae and do noi use it,
Perform resectional debridement in healthy liver tissue
TOP KNIFE The Ad & Croft of Troumo Surgery
Hepaiic artery ligation is siill meniioned in trauma texts as an effectivehemostatic_ techn iq ue. Some surgeons use ji for ongoing arterial bleedingnoi controlled by oiher means. We have not used this iechnique in years.
How about drainirg the inlured ljver? This is a somewhat controversjaliopic. One of us routinely drains all high-grade liver ifjuries using a closedsuctiof drain, while the other almosi never does.
Rehohepatic venous iniury
Gushing dark blood from a deep hote in the tiver or from behrnd afdaround t usually means an njury to either the retrohepatic IVC or hepaticveins. These encounters are rare, brief, and brutal. [4or€ often ihan fot,the result rs of-table exsanguination and a very frustrated surgeon.
The retrohepatic veins are ihe east accessible vascular siructures inthe abdomen. You cannoi get to them and define the injury unless yousomehow control the hemorhage. The classic technique to accomplishthis rs the atriocaval (Schrock) shunt, one o{ ihe ,,great technical feats,,oftrauma surgery. You willfind elegant lll!stralions deprcting ihe technique nevery malor trauma book, bui not rn ihis one. Why? Because if real life ilvery rarely works. In fact, even rn the most expeienced hands, theatriocaval shunt has drsmal results.
l rstead of engag ng in Jut le heroics, use common sense. Theretrohepalic vetns are a lowpressure sysiem amenable to containmentand tamponade. Your best move, therefore, is to contain the injlry, not tryand fix it. A retrohepatic venous injury bleeds freely only if one or more ofi ts containmert structures is disr!pted. These structures are ihesuspensory ltgamefts of ihe liver (markirg ihe borders of the bare area),ihe right diaphragm, and the liv6r itsetf.
Your realistic opliofs for dealing with a retrohepatic venous injury are:
a Leave a contained retrohepatic hematoma alone. Don t mobiljze theliver and don I try to explore the hematoma. Just move on io otherinjur ies {and count your btessings).
a
a
6 The lnjured Liver: N njo Moner
l{ dark blood is gushing out from a deep hole in the liver parenchyma'
pLug the hole. Pack ii with a laparotomy pad, viable omentum' or
balloon iamponade. Whatever ii takes - iusi plug the hole'
Don't open 'Pandora's Box (Chapter 10) A hole in the r ight
diaphfagm bleeding inlo the chest in a patieni wlth penetratrng
thoracoabdominal trauma can hide a retrohepatlc venous rnlury
Simply close the hole and don t mobilize the hver'
When bleeding emanates ffom behind the liver, iry to determine if the
source is below or behind the liver. Injuries to ihe IVC below the liver
(ihe pararenal and suprarenal segments) afe accessible to direct
repair. lt's difficult, but can be done.
lf the suspensory ligamenis of the liver are distupied, your best
chance to control the bleeding is packing ihe area quickly and tightly'
Wiih limted disrupiion of the ligamenis, you may be able io re_
esiablish conlainment with packing. Wiih massive disruplion, often
associated with a high-grade liver injury the battle is usually losl even
before you siad Packrng.
Should you even consider an atriocaval shunt? lt may be a realistic
option, but only under very speclflc circumstances' You need two teams
of experienced surgeons who can work simullaneously in the abdomen
and chest, the necessary equipmeni must be available, and bleeding must
be temporarlly conirolled while ihe effod is organized
The techn que entails a med an sternotomy, a purse_siring suture In lhe
right atrial appendage using 3:O poLypropylene and a Rummel tournlquet'
and encircling the supradiaphragmaiic IVC inside the pericafdium wiih an
umbilcal iape on anoiher Rummel iournlquel We use a size g
endotracheal iube, clamped proximally, with a side_ho e cui 17cm Jrom the
tio. We insert the shunt wiih the curue of the lube facing anterlorly so that
the lip does not end up in lhe hepaiic veins The surgeon operating in the
abdomen directs placemeni to prevent shunt efrusion through the injury
The baloon or lhe IuoP oovia-es lhe need ror encrc ng t1e s ' lora-erel
IVC in the abdomen. The shunt does not provide a completely dry field bui
ooes arlow yoJ to see .he inlLry and gel Io t
a
a
ln retrohepatic venous iniury, restore containment - don't be a hero
IOP KNIFE The Art & Croft of lroumo Surgery
The "evil green eye"
For obvjous reasons, injuries to the bjliary traci are often assocjaledwith hepatic trauma, and leaking bile is a jower priorityihan spurting blood.What are your damage control and definitive repair options for the injuredbiliary tract?
A perforated gallbladder can be repared, drained, or femoved. Thedef ini t ive solut ion is that rare, almost ext inct operat ion , opencholecystectomy. ln a crashing coagulopaihjc patient, taking thegallbladder off the liver is not the smartesi move in the book. tnstead,either repairthe laceration wjth a single layer ofabsorbable suture or drainthe gallbladder with a cholecystostomy tube inseded through the injuredfundus and secured with a purse-string suture.
The damage control soluiion for cor.mon bile duci injuries is exiernaldrainage. lfyou need to bailout in a hurry, cannulate ihe proximal duct andbring the drain out through the abdominal wall. Ligaiing or clipping thecommon duct ofa patient in dire siraighis is an acceptable darnage controlopiion, but will require a complex reconstrucilve solution at reoperation, lfyou can' l see ihe leaking hole, a drain in Morr ison's pouch is goodenough. The leak can be managed later by ERCP and endoscopicstenling.
lf you can clearly see ihe injury and the com.non bile duct is wideenough to accommodate a T-tube, this is a good bail out option. However,the common bile duci of most young irauma patients is narrow anddelicate, and inserting a T.tlbe into it may well buy youf patieni aposloperatve stncture,
The definitive repair of extrahepaiic biliary injuries depends on themagnitude of damage. Repair a simple laceration (partial iransection) withan absorbable sut!re and an external drain. Allhough it is not mandatorywe lnsert a T-tube in the common bile duct if it is of sufficient caliber toaccommodaie at /east an I French tube. If you decide io use a Ttube,always insed it ihrough a separaie choledochotomy rather than ihroughthe Inlury sile to preveni a stricture.
6 The Iniured Llven Ninio Moner
Deflnive repar of complete or near_compleie transeciion of the bie
duct is with a Roux_en Y hepaiicojeiunoslomy Before you begrn' a
cholecysieciomy willfaciliiate access and exposure of the injured duct
Drainage is the bail out solution for biliary trauma
T H E K E Y P O I N T S
) Control the l ivef tempofar i ly using hand, pack, or c lamp
) lvlobilize ihe iniured lobe to deal with it face{ojace
> Decide if you are dealing with a small problem or BIG TROUBLE'
) Consider angiographic embolizaiion as an adjunci io packrng
) Deep liver sutLrres are noi a crime
) Hepatotomy wiih selective llgation is easier said than done
) FiLl large parenchymal defects with omentum
) Balloon tamponade is a cool soluiion for a bad problem'
) Perfom reseciional debridement in healthy liver iissue
> In fetrohePatic venous lniury' festore containment'don't be a hero
) Drainage is ihe bail out solution for blliary irauma
TOP KNIfE The Ari & Croft of Trqumo SLJrgery
Chapter 7
The 'Take-outable" Solid Organs
Fot eztery complex ptoblem, thete is a
solution that is simple, neat, dnil Tototrg'
- H.L. Mencken
Although they belong to different organ systems, the spleen, kidney,
and dlstal pancfeas have a lot in common From the trauma surgeon's
perspective, they af€ close relatives because they are 'iake_outable '
Consider the fundamenia dlffetence between an injured spleen and a
bleeding liver. The spleen has a single accessible vascular pedicle thatyou
can rapidly gel io and control The liver has two vascular pedicles (one in
lhe hepatoduodenal ligament and ihe othor behind the liver where the
hepatic veins drain into the IVC), only one of which ls easlly accessible'
Toial vascular control of lhe liver is, therefore, iricky businsss lt is noi a
take-outable organ in the bleeding irauma patient.
It n6ver mad€ sense io us to consider both head and disial pancreas
(body and tail) in ihe same chapter' From lhe irauma surgeon s poLnt ol
view they are differenl organs The distal pancteas can be easily resected'
while the panctealic head requLfes a very brg whacK
The spleen, kidney, and distaL pancreas are take_oulable abdomlnal solid
organs. They can bleed a lot b€fore you get to them, bui once you have
gained control of the vascular pedicle, bleeding stops immediately The key
to vascular control is mobilizing each organ and fting it toward the midline
In stark contrast, resection of a 'non'take_outab e ' so d ofgan such as lhe
liver or ihe head of the pancreas is a prohibiiive technical undertaklng in the
lrauma patient unless the injury has done most of the resection tor you'
At firct glance, bringing together three solid organs from three different
organ systems under the same foof may seem strange to you Bear with
IOP KNIfE The Ari & Croft oJ Troumo Surgery
Lis, and your undersianding and comfort jevelin dealing with these injurieswill grow
The spleen
Mobilization
. If you see or suspect a spienic injury your first move must be mobilizingthe spleen to ihe midline. You can nejiher adequatety assess nof repairthespleen wiihout having ii tn your hand. Mobilizing the spleen is the keymaneuver that unlocks the left upper quadrani. lt brings the sp/een anddrstal pancfeas oui of the dark recesses of the abdomen jnto your incisionand exposes the left kidney. White mobitizing the spteen is a basicmaneuver rn surg€ry, pedormjng it quickty, btindty, and tn a poot of bloodis not as it appears in the illushaiions.
Mobilize the epleen to unlock the left upper quadrant
You may not have heard this before,but in reality (as opposed to the virtualworld of the surgical atlas), ihere aretwo kinds ofspleens: mobile and siuck.
The mobile spleen has lax spleno,renal and splenophrenic ligamentsand no adhesions to the abdominalwall. By putting your non-dominanthand over the splenic convexity andpul l ing medial ly, you can brng thernobile spleen toward you, almost iothe rnidline. You still have 10 cut thesplenorenal l igament behind ihespleen, but this is easy because youdo it a/mosi in the midline raiher thanhigh up in the left upper abdornen.
The spleen, kidney, and tailof the pancreas are take-outable
7 The Toke-oLrtoble So icl Orgons
The siuck spleen is, you guessed ii' siuck To gel it to the midline' you
have to deal with two obstacles. The firct are adhesions beiween the
splenic capsule and lhe abdominal wall ihat will not let you pass your nano
over the splenic convexity- lfihere is little or no bLeeding, you can take your
iime and ;harply divide ihe adhesions with scissors or cautery But if you
are working in a poolof blood, just do whalever ittakesto quickly gel them
oui of ihe way with your fingers, scissors, or boih Damage to ihe splenlc
capsule doesn t matier since ihe sPleen is coming out anyway
The second obsiacle wiih ihe stuck
spleen ls a short and unyielding
splenorenal ligament. Put your non-
dominanl hand over the spleen so the
tips of your fingers resi on the
menrbrane behlnd and lateralto it This
is the splenotenal ligamenl Gently pull
the spleen toward you io stretch ihe
ligament. Working in a pool of blood,
you often cannot see [, bul you can
easily leel it. lmmediately beyond the
tips o{ your fingers, make a nick in lhe
streiched ligament wiih your scissorsEnlarge the-nick sharply (with scissors) or bluntly (with your {ingers) up
and a;ound ihe spleen Both the splenorenaland splenophrenic Ligamentsare avascular' and dividing ihemallows you to bring ihe spleen to ihe
midl ine.
Palpate the left kidney and bluntly
develop the plane behind lhe spleen
and in iront oi the kidney, bringing the
spleen and tailof the pancreas up into
the wound. The piifalL here, especLally
in the prcsence of masslve bleeding'
is going behind the left kidney and
discovering thatyo! have brought lt t0
the midline wiih You.
TOP l(NtFE The art & Crofl of Troumo Surgery
Once the spleen is mobilized andin your hand, bleeding control is nota problem. Pinch the splenicvascular pedicle, which includesboih the gastrosplenic l igament(carrylng the shod gasiric vessels)in front and the splentc hi tumbehind. Alternatjvely, place a softbowel clamp or a large vascularciamp globally across the entirepedicle if you have other urgenibusiness to aitend io first. Think oft as the "Pringle maneuvef of ihespleen."
Remooe ot rcpab?
You are now facing the key slrategic decision ln sp/enic trauma: romoveof repair? Splenectonry or splenorrhaphy?
Rarely, on a particutarty bad night, you may find yoursetf gazing indisbelief ai the ruptured spleen from hell, a diseased organ so enlargedand stuck to the abdominal wal/ and diaphragm ihai rapidly developing aplane behind ii is slmpy oul of the question. ln this case, your only optionrs 10 altack the spleen from the front. One qulck way to conirol the splenrcarleryis to enre. rhe lesser sac lhrougn the gastroco ic omentum a,toisolate ihe artery along the upper border of ihe pancreas. Another oDtronis io go srrarght al lhe hilLm. Gentry pull tne stomach towaro you Lo put tlFgastrosplenic ligament on tension and divide it between clarnps.lmmedialely behind rt you will find the splenic hilar vesse s. Clamp themand only then start yo!r dissection io fiee and mobllize the devasculafized
Do what it takes to bring the spleen to the midline
7 The Toke ouiobe solld orgons
Your answers 10 the iollowing fout quesiions guide your decLsron
1. What is the patienl s traun''a burden? Ongoing sl^ock s"vere
associated iniuries in or outslde the abdomen _ all are indications to
rapidly Put th€ soleen In a bJclet.2. Whai is the patieni's age? Spenjc pr€seruaiion is much more
important in kids. Splenonhaphy also works betier ln the pediatrlc
spleen because it has a lhick capsule ihai holds suiutes welL'
3. iow bad is the iniury? ls a repair llkely to work? ls there a hilar iniury
that makes repair much more dif{icuh? Will a r€pair entail additional
bLood loss? Never make this decision wilh ihe spLeen in siiu Always
bring itto ihe midline and assess the lnjurywrth the spleen in your hand'
4. Wh;t is your experience wilh splenic tepalr? Have you done it before
or is i t a ' read ons, do one'si luat ion? ls the injury amenabLe to a
reparr iechnique ihat you are comfortable wiih?
t ,l compteung the s1lenecto,nq
."t /' CJi""'y Lo the imor€sson you may havo fro.r reading the rauma7 t I literalure ol the pasl decade, splenectomy is not a crime lt is otten ihe
safest and mosi expedient solution One very effectlve technique of
splenic preseruation is the {omalin jar
Once you have the mobilized
spleen in your hand, comPlel ingthe splenectomy is easy Clamp
and divide the vessels of thesplenic hilum from the back or
side, whichever Ls mosl
convenieni. The key technicalprlnciple here Ls to stay very cbse
to the spleen so you wi l lnoi in jure
the tail of the pancreas or lhe
siomach. Fot the sake of sPeed,
For splenic repair, considertEuma burden, age, injury, and experience
TOP KNIfE The Art & Croft of Trouma Surgery
camp oniy ihe proximal side of the line of resection. Clarnping the spleensrde wastes time since it comes out in a moment anyway, Serially clampand divide the gasirospJenic ligament, taking care to stay away frorn thegfeater curve of the siomach. The splenocolic ligament is ihe onlyremarning attachment. Clamp and divide ii, and the spleen is out.
Now pick up the ciamps one-by-one, and ligate the vessels ihey arecontrolling. You may declde to doubly ligate or sutureligate the hilarvessels. Re-examine the greater curue of the stomach to ensure you didnot accidentally pinch the gastric wall. Much has been written aboutratrogenic jnjury to the tail of the pancreas during sptenectomy. Thjsconcern rs much overraied. lf you think that you may have iniured thepancreas whie removing the spleen, leave a closed suction drain in thesplenic bed.
Lasty, check for hemostasis_Suck oui al l the b ood and clots inthe splenic fossa. Take a tightyrolled laparotomy pad, go io thedeepest part of the splenic fossa,and slowly ro/l the pack iowardyou medially, over the area of ihepancreatic tail and the greatercurve. ll you identify a bleeder,stop rolling and deal with it.
,..\
ij
Stay close to the spleen
\ ^ Y r {Fixing the injurcd spleen
lf you decided to repair ihe spleen, use ihe simplest technical solutronthai will work. Choose fronr a limiied menu of repair rechniques that haveworked fof you in ihe past. Few surgeons have experie|ce wjth a vasiarray of spjenjc repair methods. What are your realistic opiions?
7 The Toke oulobe SoLid O'ncl"t E
Local pressJ'e lwrlh yor- hand-or a pachl wor\s in super{ 'c ia
laceratro']s and capsLlar avu's;or- Your lavorfte rocdl hemostairc agert
""" .f". n"fp fn" ,q,g"n beam coaguiator' if availab/e' does wonders for
a larger raw surface or a deeper laceration-
Because the caPsule of lhe
ad!lt spleen does not hold sunrres
w€ll, use a rnonofilarnent suiure
ihat slides through the tBsue,
along with some klnd of bolster or
support. Our PreJerfed technque
is running a mono{ilament suture
on a straight needle between two
stdps of Teflon on both sides ol
ihe laceration Sorne surgeons
use omentum as a boLsler.
A severery rlu'ed or o^vitalireo soleniu pole ray r"qu're a "mired
;;;". #"" ;"", """istant manuallv compress the spleen lusi bevond
;; , ; ;""" l i . " ; ' ' """" Ion .o conrol b 'eedirg lntermit .nt lv reeasi 'g ihe
0."J",'" .**. t", **'e the olPeders are -o vo"r::: ':lH T,i.il
Argon beam You can then
oversew the op6n splen|c's iump' with matt fess
sutures between two sirips
of Teflon. lf the sPleen Ls
flai rather than bu kY,
another oPtion is using a
linear staplef wiih 4 8mm
staples. Bring the stapLer
io the line o{ transectionand slowly close I so as
noi to break the caPsule.
Fire ihe staPler and
amputaie the sPlenic tissue
disial to the staPled line.
E ,o, ^",r, rn" o,, & cfofl of Tfoumo sureery
-, Don't persist ifyour repair doesn,t work, and don.i reiy on the patient,sCott'ngmechanism to sioo orgoing oozirg. ,lf i air,, ary. ,t s noi wor"r,.g."In ar adL[ patient. we proceed wttn splenectomy i, rhe fts, aftemp;drepairJaits. tf you sirongty betieve thai repair is stifitf.," Uu.t option tofifrJpalient, you may try a second time_ A tnira atrempt rs ptaying wirh fjre.
_ We have.g:ven you ihF hmied.ienu of sptenrc rsoair ,ech n iq uFs we Lse
:,:1:li::i"", sorry if you are disapporn,ed. We have ,itr,e experielcewllr Tormat tem,splenectomy or tre absorbabte mesh wrap. We consioe.rnem unlecessaflly risky acrobaics. lr siuatons where these tech'rrqueswould be requhed, we prefer io en on the srde ot caution and do asprenectomy.
Don't persist if splenorrhaphy doesn,t work
The distal pancreas
ENplolation
You can have a quick'ruleoui' look at the body and tailof the pancreas thfough thelesser sac by poking a holeIn the gastrocoiic omentumon the tef t (Chapier 4).However, i f you see orsuspect an injury, you need awrde exposure. Have yourasststani pull ihe stomachupward and ihe transversecoron downwardr and detachthe greater omgnium fromthe transverse coJon a/ongthe bloodless line io openthe ful/ width of the tessersac. Wjih any sign of Injury,
open the posterior peritoneum overlying the injured area What.you
;;"";; i" be an innoLenr-looking minor hernatoma or superrical
i"""*." *,, .f,"^ oro"e a s€t;ous Injury wh"n you un'oo{ it and look il in
fie lace.
7 The rake-oirioble soio orgons I
For signi{icanl injury, and
especially if You are going lo
resect the dislal Pancreas, the
quickest way io bring ihe body
and tail into {ull view (including
the posterior asPeci of the
gland) is to mobilize it out of ils
bod. Mobilize ihe sPleen and
continue to develoP ihe Planebehind the Pancreatic iail and
body until it can be lifted
medialLy lnto the operative
incision. Distal Pancreateclomywithout splenectomy rs an
€laborate exercise suitable
mosily to an elective situatron.
We do not recommend nor use
it in trauma panents.
Decision
ls thete a ductal injury? This is the key quesuon whan assessrng Ine
iniured pancreas someiimes you immediately see that ihe pancreas ls
;;;;iJ ",
vou can rdenlily lheinruted duct in a deep wound ['4ore
ot "n,
you ""n;ot
tu," out a duclal 'niury based on Inspeclioi and palpanon
alone. What then?
Iook "t
the pan"reat from the front - but mobilize it from the left
E ,o, *",rr rn" orr & cfqfj of Troumo surgery
ln a stable patrent wiih no othef maiof inire,ercise ca red,nraopar,, "; r";;.;;;:;#;:;jJ:i;T,:lj"'j;::ilI:
II.e ga,'bladder rrrough a reedle and -catn.rer
aro pray rhar rt n,ts trepancreatic duct in a retfograde fashron ihrougt th" urputu. eropon";iiof this technrque cJaim ji works about half the time. In "rl. ",,p";i;n";;;ra,'ely does. B.euaLsp lhey a,e toratty Lnnece,sary, we don | -euommero
olTer opfons I ke ampurat ng tne ta,r or t re panc.ea5lo n^o the dJc- or Ineabsurd notion of making a duodenotomy io cannuJate the papilla.
-^Y" ! ' :* r : : c:Tmon sense. . \pedien- aop,oacr. f Fypto.aion
revears a oeep InJUry l iJ<ely to. .vorus,1.," 6u" ' , Oo 1ol hesi tate ro pertor_a orslat pafcreaiectomy, even wiihout definitive proof of ductat injury. lf we
P:^r, ] : l * ' : ""1
" ."eed-o bait oL, oLiLkty. w" , ,"""
" o." ,n
" ; ; ; ; ; ; ,'o lhe InJLry dnd perform ar ERCp as \oor as oossib,e afte. ihe operairor,fealizrng thai we may occasionally have ro go tJack for a disial
Hemostasis alriL ahg Mge
The damage control soluiion for injuries to the pancreailc body and tailrs hemostasis and drainage. pack *e lesser sac for hemosiasis. A drainconverls ihe injury from a potential uncontrolied pancreatic leak into acontrolled fisiula ihat has a befign course afd can be addressed laier
, .Def.ni :vF mdnagFmenr oi mosr drslar panc-eaic injLr ies is no_ -uch
i i l ' " : ' "* 1l^e damage co' lnot ooiro' l . Slop b,eFdrrg from supFtiL a,
raceratons and conlusions using localhemostat ic means. Don,t sulure ihecapsule of ihe pancreas because this js asking for trouble. Leave a Jargesuctrojl drain,(or two) adjacentlo the injury, feed the patient as early;spossrbre, and renrove the drain when it stops working. For pancreaticinjuries that do/r't involve the duci, ihis is a yo! need to do.
^ ^ryTl *" ,s oovious ouda :njury or when you have d srrong
suspruror about the d rct bur ua-no- prove i l . do a drsta,panc.eatecromyi
You don't need photographs to deal with a pancreatic injury
7 The Toke-ouioble Solid Orgons
lf you happen to come across the
pancreata duci, ligate it Otherwise,
don'i spend time looking {or it. Liit
the spleen and the Pancreas to the
midline, lake a linear stapler, place it
across ihe body ol the Pancreasincluding ihe splenic vessels, and
shoot. Amputaie the disial pancreas
and spleen and give the Pancrcaticstump a close look Control any
bleeding from the splenic vessels
with a hemosiatic atiich. One ol us
usually undeffuns the siapled line
with a 3:O monofilament non-
absorbable suture; the other nevet
does. Don't forget to leave a closed
suction drain in ihe pancreatic bed
Damage control lor the distal pancreas is hemostasis and drainage
-''N5t(^\D\-- '+ @ *"*tH
The kidneys a s!,rl,r" + c.^l,alt r'.-{,&}.-&
Access &nd otlscttltu contxol
At laparotomy, the iniufedkidney iypically presents as
a lateral feiroPentoneal(perinephric) hematoma(Chapier 9). Deal wth a
massively bleeding kidneY
in an unstable Patient b),rapid mobi l izai ion and
contfol of the vasc! larpedicle, just l ike You deal
with the iniured spleen A
E ,o, *"'rr rn. o,r & crofi or TroLJrno sursery
mediai visceral rolation (Chapter 4) on the left or on the right gives youftpld access to the injured kidney. Incise Gerota's fascta taieratty anj iiftthe kidney out of its bed. Now you can pinch the hitum with your fingersand carefully place a vascular clamp across tt to control the bleodino. Theobvious sjmilariiy to th6 spleen is stfrking.
Bring a massively bleeding kidney to the midtjne
l f you must explore apennephflc hematoma In a
Egllq) patjent, you can gainvascular conirol of the renalvesseJs at their origin byusing a maneuver cal lednidline looping. Wilh thismaneuver, you obtain proximalcontrol prior to entering thehematoma, but ai the priceof tedious dlssection. Thelrrst moves are essentiallythose of infrarenal aodicerposure, Eviscerate thesmall bowel and pull it upand to the right. Take downthe ligamont of Treitz andopen the poaterior periioneumoverlying lhe aorta. First, identify the LRV crossing in front of ihe ao abeneath the infefior border of ihe pancreas and encirc e t with a vesselloop. This is the first of four toopings. Very gently reiraci the LRVdownward (withoui avulsing the adfenal, left gonadal or lumbar veinsthat branch of{ jt), and you will gain access to the left renal artery takingoff irom ihe ao a behind and above the LRV pass vour second vesselloop around i t .
Midline looping is trickier on the right_ you must first identify and looDihe srorl right'enal ve:n: then. dissect n tne wrndow betwee; t and tneIVC to oop the right renal ariery as it emerges from behind the IVC. AJI
7 The Toke ouloble Solid orgons
this is iime_consuming and opens the door io potential pitfalls We
consider it a long run {or a short slide and rarely use it You can easlly get
tv without it if vo-u rememberto rapidly liftthe injured kidney io the midline'
iusi as you do wiih the sPleen
What af€ the damage
control opi ions for renal
trauma? One obvious
option ls nol to explore the
kldney. lf the PennePhnchematoma is slabl6 and
non-expanding, leavo i t
alone. lf you see oozing but
no massive hemorfhagethrough a hol6 ln Gerota's{ascia, pack the krdney
Remember thai ur ine
exiravasalion |s much less
ominous than leakingintestinal conteni (Chaptet
4).
lf the kidney is bleeding massively and is obviously not amenable lo
reconslruction; ot has a hilar vascular lnjury in conjuncrion with oiher life_
lhreatening iniuries, a rapid nephrectomy is lifesaving Lift lhe mobilized
kidney up, id;ntify the artery and vein, sutureligate the artery and tie off
ihe v;in. Then, divide th€ ureter between ligatures and pui the kidney in
When considering your oPtions, always think about the contralateral
kidney. You will go the extfa mile and invest addltlonal effod in renal
preservation ifyou know thatthe paiient does not have another functioning
iidnev. lf vou do not have preoperative imaging to prove afunctloning renal
mass on the other side, what should you do? An on_table intravenous
oveloo.ar to prove ihe presence ol a lLnciion ng confalatera renal mass
is ore'option. Tl^is takes t -e and otler yields an rrialing lLzzogram ralher
than a satisfactory image A better option is to palpate lhe othet kidney lf
it feels normal in size and consistency and the patient is making urine
TOP KNIFEThe A.t & Crof l of ]rounro Surgery
despiie a. hilar clamp across the injured kidney, the risk of postoperativerenal dysfunction is very small.
Palpate the contralateral kidney
. Repaif.oplions Jor the injured kidney cover a wroe epectrumj ranging
lrom application of top ical hem ostatic agenl to extracorporeal bench repairwrth auiotransplantation. The best advice we can give you is don,t usethem. CaJl a urologist in to repair the kidney. An experienced urologist ismore likely io achieve a good result, will foliow the patieni, and m;nageany cornpllcanons.
/ . 1 - J V , r ^ 1Repair of renal vascular injuries (both blunt or peneirating) is much iess
coramon and rnore challenging than the trauma iterature leads you tobelieve. On the right srde, penetfaiing hilar injuries are iypically part ofwounds to ihe surglcal soul one of the most devastating combinaiions ofinjuries in tfauma surgery (Chapter O). The proximity of the renal hjtum toihe IVC means that a penetrating injury will involve boih ihe renal arteryand lhe IVC or other adtacent siructlres like the pancreaticoduodenacomplex. Inj!ry to the short fight renal vein is essentially a side-hole in iheIVC, for whlch the pime concern is control of liJe-threaiening hemorrhage,not renal salvage. On the left, don'i hesitate to ligate the renalvein if it tsInured proximal to its gonadal and adrenal branches. The N4attoxrianeuver (Chapter 4) gives you excellent access to ihe left renalartery.
When dealing wrth an ischemic kidney after bJunt iralma in a stablepatieft, your decision to revascularize ihe kidney hinges on ihe Umeelapsed since injury, presence o{ functionjng contralateral kidfey, thepatieni s overall trauma burden, and availabie expertise. l\,,lany of theseInlunes are amenable to endovascular stenting, Never jeopardize thepatient's lile to save a kidney.
ll you are fixing an inj!red renat ariery, perfuse ihe kidney intermlttentlywith iced heparinized satine and choose the sjmplest repair optiof. Jf theartery can be repaired end-to-efd, go for it. More often, you have iointerpose a graft. The graft of choice is probably a reversed saphenousvein, bul ihe most expeditious option js a 6mm epTFE condujt. Hook it up
7 The Take-outoble Solid O,S.", g
io ihe renaladery (distal anastomosis) first because this allows you better
".|e"" ," tr't" posterlor *atl of the anastomosis Choose a convenient
L"ation on tne lat"rat u"pect of the inftarenal aoria' convol ii wiih a side-
Uiti"g autp, and do a small aoriolomy Trim the graft and comPlete the
pror-mal anastomosis lo the aortotomy in an endio side confiquration
T H E K E Y P O I N T S
) The spleen, kidney, and tail of the pancreas are take_ouiable
) Mobilize the spleen io unlock the left upper quadrant'
) Do what il lakes to bring the spleen io ihe midline
) For splenic repair, consider trauma burden ' age' injury' and experience
) Stay close to ihe spleen
) Don t persist if splenorrhaphy doesn t work
) Look at ihe pancreas frorn ihe tront-but mobilize it fior' the leJi
' You don't need photographs to dealwith a pancreatlc rnlury'
) Damage control for the distal pancreas is hemostasis and dfaLnage
) Bring a massively bleeding kidney to the midline
> Palpaie the contralateral kidney
) Don t killthe patieni while irying io save a kidney
Don't killthe patient while kying to save a kidney
E ,o. *",rr rn" o,r & crofi of Troumo su,sery
ChaPter 8
The Wounded Surgical Soult!a-,.'a^* e (vQ i^ "/''r+vu'! t ')u7
Medical ill strators arc optifiists.
It's dilficult io imag nea more unwelcome sight
during laparoiomy rorpenelraiing trauma ihana arge hematoma orvigorous bleeding kom
the dght upper quadrant
beneath the Liver. l{ ihis iswhat you see, you havejust been dealt one oi ihe
worst possible hands in
the l rauma game. Wecal l ihese injur ies thewounded surgical saul
- Matthew J. Wall, Jr., MD
l.
According to iraditior in
our hospital, ihe seat of the soul of lhe injured patient is a sphencal area'
not much larger than a silver dollar, centered on the head ol the pancreas
They afe called soul wounds because they are mofe lethalthan any other
type of abdominal trauma
A glnshot to ihe surgical soul commands ihe greatest respect from
trarmi surgeons because i t f requent ly eads to intraoperat iv€
exsanguinat ion. You may ini t la l ly encounter a contained or slowly
expan;ing hemaloma lhat doesn'i look particularly ominous But once you
open it and unroo{ the underlying major vascular injuries, the demons are
unleashed and the pat ient exsanguinates in your hands Another
unwelcome s!rpdse is when a novice pokes an exploring Iinger into a soul
wound, onLy io face torreniia hemofrhage when the ptobing finger is
withdrawn. Why are these nluries so Problemaiic?
E ro, *"'rrTn. o,r & CroJi oJ Tfoumo su,oerv
First, consider the vascuJar anatomy of the area. The portal vein, thes!penor mesentefic vessels, the pancreaticoduodenal arcade, the IVCand the righi renal pedicle all converge ai the surgical soul. Since some ofihese vessels directly oveflay each other, a penetrating injury iypicallyin/olves more than one major vessel. Now consrder accesstbtlty, The neckor tlre pancreas overies the podal vein conJluence and the proximalsuperior. mesenieric vessels. The pancreatic head and duodenal loop(reJerred to in ihis chapter as the pancreaticod!odenal complex) cover iheIVC and right renal pedic/e. So, none of ihe vessels is easily accessible.The situatron has worst-case scenaio wrjnen al/ over it. A discipllned andpriorrty,oriented approach is your only hope.
Immediate concetns
Yolr first priorty wlih soul wounds is to contro her.orrhage. Alwaysassr.rme lhal bleeding is from more than one major vascular injury untiproven otherwise. The major bleedlng sources afound the surgical soulare arranged in ihree layers: deep, middle, and superfrciai.
2.
L fhe deep layer includesihe IVC and the righi renalpedicle. You wi l l see araprdly expanding r ighr-srded retroperrioneal hem-atoma or active bleedingfrom the area of the righrrenal h Ium- Pack ormanuarry compress i t .Don't unroof it.fhe niddle layer irc)udestfie retropancreatic vessels:the superior mesenter icartery (SIMA) and vein(SMV), and the portal vein.The secret of tempofaryb eeding control ts rapidmobilization with a Kocher
-\ j i . ' . - ----- ' - ' - .
\:1,- -:1.)
sThe wounded sursrco sou g
maneuver (Cl'dple'4). lf bleeding is {ron the rool ot lhe mesentery
iJ"t i."rJ., ,"f *" o"ncreas' control it by insinuating your lelt hand
s.i-i"a'iil ."t or tr',..eseniery and pinching it beiween ihumb and
{oref,noer. l{ the source o{ bleedrng is beh no the oarcreas mdnJally
"ompr'"ss t're ent're pancreat;coduodenal complex Temoo'anLy
control bleeding fiom the hepaioduodenal ligament by pinching the
portal triad (Chapter 6)
3. fhe su?erticial laYer
consists of ihe iniuredpancreat icoduodenalcomplex rtself. Injury io
the head of the
pancreas can be lhe
source of brisk bright_red bleeding from thepancreat icoduodenalvessels, Here again,ihe quickest way togam temPorary conrrcl
is a Kocher maneuver'
which enables You to
comPress the entirepancreai icoduodenalcomplex in Your hands
of encircle il with a
Penrose drain lo gei
temporary hemostasis
Some soul wounds bLeed {reely into the peritonealcavity' while others
DTesent as a conlarneo he_laroma Co'Irol o ' i 'ee bleeding comes t l rs l
Never ever 'pote a skunk' by enrenrg a coniained hemaLomd unl i al l 1€e
bleeding has been controlled and you have organized your attack'
Supraceliac aortic clamping is a useful adjunct in a cfashing patient
Double clamping of bolh the supraceliac and infrarenal aorta (to control
backflow) helPs reduce bleeding Jrom iniuries to the superlof mesenlenc
vessels and the portalvein bui will nol dry up lhe operative field'
E ro, **,rr rn" o,i & croit of Tfoumo sursery
, All this seems nice and neat when siiijng at home readjng (of writing)
about ii. But the professional term for what you meet in real life is mulr.,tocal exsanguination, rapid bleeding from muhipte sources, none of themeasy to control. A less professionalterm is bloody mess, and you have nor/me to consutt www'broooymesc.org fo. aov.,e, roJ must starncn rheb/eeding NOW usrng a coF,binat io 'r of odck ng, the Kocrer mareuvelmanuat pressure, and careful clamDino
once you. have gain.a t"mpo*r; c*trot oi hemorrhage, stop iheoperation and organize your attack on the injury. Don,t jusi dive tn wlihoulappropflate Instruments, plenty of blood units if ihe OR, an auto-t 'ansfus:on dFvtcp. a rapid,nfLser ool imdlexposu.e. ano comoetenr help.r l 'eeorrg rro- d soul woJrd rdkes BtG IROUBLE {Chaptpr 2) to a rewlevel - TREN4ENDOUS TROUBLE.
Soul wounds bleed from more than one vascular iniuru
Imptoving exposure
The key to anfhing youmay need to do aroundihe surgtcal soul is ihewrdesi possjbie Kochermaneuver (Chapter 4).For bleeding from thedeep layer ( lVC afd r ightkidney), extend theKocher maneuver into aful l r ight-sided medialvrsceral roiatron by mob-iJizing the right colon andretract the liver cephalad to create a wofk space around the pararefallVC. l f the r ight fenat hi tum is involved, mobi l iz ing the r ight k idney out ofGerota's fascia afd rotating it medially helps you gain control of ihehi lum.
I The woLrnded SurgicolSou!
Use the Cattell_Braasch
maneuver (chapier 4) io obiain
lhe widest possible exposure oi
the sufgical soul This
maneuver uncovers the third
and fourth Parts ot the
duodenum, allows You to reach
ihe pfoximal SMA and SMV as
they emerge beneath ihe neck
of the pancreas, and even gives
you some access to ihe
relropancreat c ponal veLn
lJse the Cattell-Braasch maneuver to expose the surgical soul
The supraduodenal Portal vein
InjLiry to the supraduodenal Porialvein is usually associaied with a high_
orade iiver 'rju-y ano p'esFnls as a hematoma In the hepalodJodFnaL
ioament. The Do,Jble Pingte -aneuver rs the texlbook_recornmendpd-
technique for de{inilive conlrol ol
injury to the portal triad, including
the suptaduodenal Portion of theponal vein. Begin with a Kocher
maneuver; then, coming from the
right hand side, Place one
vascular clamp irnmediatelY
above the upper border ot the
duodenum. Place a second
vascular clamp across the portal
iiad, as high as Possible ioward
the liver hilum. This allows You to
open ihe serosa of the hepato_
duodenal ligament and carefully
E ,o, *",rr rnu on & crofr of Troumo surgery
o.ssecl lo derile the iltury. UnfoaunarFty, lhe hFpatoduooenaloner too shori to acuommoda,e two clamps. A good ahe.nativeIne InlL'ed ar€a wth yoJr,eJl ha'ld while dissecting dbove andinjury with your right.
A/ways assess all three elemefts of the portal tflad because their closeprox/mfiy makes ii very likely ihat more ihan ore siructure has been hit. Asiab iypically causes a clean laceration of the portal vein and js amenableto a e'al repai l - contrast. gLnsho, .n,uies LaJSF Tasstve desiucirontusuarty rr coryunct ior wrth a. i rer i r 'ury1. reoLinlg a complFx repair s,chas a patch or rnterposjtion graft, which is rarely feasible in the harsh realiiyol multifocal exsanguinatron.
The oamage Lonro' soturon lof a como,er supraduodera, porat var '1rr lJry. r lgar 'on. l t rs a real ist ic opt iol and co-pa. ibte w tr sJrv.va. i r therepalrc arteJ ts intacr. Wher bo.h porta, veir and hepatic anery a-errlured, you have to reconstruct one of them
The retropancteatic vessels
InJunes to the retropancreatic vessels (the confluence of the superiormesentenc and splenic vetns, as well as the reiropancrealic part of theSMA) are particularly jethaj because you can,i get to them. pancreaijcrfans-Aclon across the neck exposes these injuries. One of us finds thistechnique useful and lifesaving, while the other avoids dividing the neck ofthe pancreas unless the jnjury has done it for rrm.
To transect the pancreas, compress ihe breeorng pancreatrcoduodenalcomplex with your left hand to temporarily control the bleedifg. Do aco-.]pele Cafel-Braasuh maneLver ro oplimtzF acLess io the complex'rom al l s.des. Rapiory create a relropancrea, ic tun,rel oy opening trehepatodlodenai ligament and blunfly dissecting immediatety to rh; teft,anterior to the common bile duct, and behind the pancreatic neck.Transect the neck of the pancreas using ihe cautery over your finger, but
ligament isis pinchingbetow ihe
Ligation is the bail out solution for portslvein iniurv
8 rhe wounded surqicolsoul A
avord ot-shing Insfuments lc'amps or slaolPrs) inlo lhe lunnel because
t"." ,l^" ""',rt""","
a retopancleai'c porta' vei'r 'njJ'y Cudng rhe
""ri".""i u.i"n" v., tace-loJace with rhe iniu'ed ra'ge vein Lnde'nearl^'
Ii"^-t", ," "oo"n-',y
to l:x i Conl'ol blFFd ng rror the eoges ol the
i"."""i*" p""f,"r. ror t'om adlacerr bleFde'sr onlv atter vou have
controlled the iniured podal vern.
It oossible, do a laleral 'epair o{ the retroparurealic veins However' d
you Jno up wiil_ a ligated {o/ oversew.]) porta' vFir a.ld a live oatierl' take
a deep breath and congratulate yoursefi
The root of the mesentery
While pinching the bleeding root of the mesentefy between thumb and
fore{inoe; lift th-e transverse colon cephalad and pull the small bowel
"-"J"tt"v "na to tn" r"t. rhis stretches the mesentery of ihe small bowel
va." jtr"n"u"r"" in"i"ion in the serosa of lhe root of the mesentery and
care{ully dissect in the mesenteric hematoma to find ihe SMA and SMV
de{ine ihe injury, and clamp Lt selectrvely'
lf ihe injury is immediatelybelow ihe Pancreatic border'
optimize your exposure b)/
mobilizing the ligament ol
Tfeilz or by doing a full
Cattell-Braasch maneuver'
The SMA is exPosed,
allowing you io Place YoLlrclamps selectively. Never
clamp blindly at the root ol
ihe mesentery' t ls a reclpe
Transect the pancreas to gain access to the podal vein confluence
. . ' l
..'. )a-.
E ,o, *",rr.n. on & croft of Tfoumo sursery
",,T:"J^:,#T" " *:. srvtA ;s di.cussed in rhe rerr chaorer. Repa,. rrerIU?o srMv rt yoJ cani i, nor. ,;gare :r. Fotlowing hgalron of Fither t1F portalvern or ihe SMV ihe jneviiable consequence js massive fluid sequestrationan^d midgut,edema, whjch translate into extremely high postoperative fiuiJrequrrements and an tnab/lity io close the aboomen, In iact, as we wrote
l,': :::o]L : l?l'*'" oLis w,rh d sou woJro u"a"*". svv ris;ri";.nrs vacLLr oac\ drdired ib i t j t t ters oi sero,rs t ,u;o fro_ rhe p"n-torea,cavty on lhe fjrsi posloperatjve day. Don,t forget that venous gangrene ofll: T.y:i
'" , oirr ncr rhrear. so atways oo a se.ond rook ."pa,o-romy roascedarn bowei viabitii!
_ The pancreaticoduodenal @mple., ..Sorie of the most fascinating reading in the trauma literaiure describespdlcr.al icoduodena, reDair tech1,o,res, spalr tng d wide .anoF o, vervrmagr'rai ve resecirons ard recorstruci ons. We a.e oa.tjc-la.,y ioro o{ ihiopirmisttc ii ustraiion of both ends of a transected pancreas ptugged into aR-ou\+n-Y tooo ol oowe,. crFalirg rwo aojacenr oarcreattcolelJrostom es
il;"l'J;j"n,." lhe prinred pase -oterates ar,.rhins. lJnfon:rar"ty.
KFeo rhngs as s.-noe as ooss:b.e. €voto acrooaltcs. and st.ck to a,mrred -enu o, sraighifo,ward ooLons. yoL wih nor f ,1d d deta led: l l_* ' t ] " . : ' " i
possibte parcred, icoouooe' la, ,ecorsrrucr ive rechlrqLesrT lFrs chaoter lastead. we give you a ve.y | _i ted m€nJ of s:-p,e a.o sateIecnn.q,res thai wo-l ,or rs. T.ree ca-dr,ral orirciple" shoLto gLioe yorrapproach to proxjmal pancreatic and duodenal injuries:
1. Dfai . every suiure l ine in the duodenum andpancreatic injury.
every signjficant
2. P.ov'de a roule for Fnlerar teeo:4q oslat to lhe duooenum, For n,tnor/rjufles. a raso,elLnaj rJbF rs an option. In _ajor 1a--a, a feedino, JetLnoslomy provrdes a crlcal nutrtrorat sdfery va ve, for yo.:r patteri3. I\,lost rmoo.ranlty, r,hoose yor_r repat. tecnn,qJe oased noi on howwpt' ,r worhs, bui on how wert it /a,/s (CrapJe, l)
Blind clamping at the root of the mesentery is a recipe for disaster
Choose your repai based on how well it faxs
l
exlernally wlth a closed suction drain
8 The Woundecl SurgicolsouL
I t3,,1'4 rh
Duodenal injuries
Can vou close ihe injured duodenum wilhout iension? ln mosi cases'
a"ti"iii'i |'"p.i|. of a arodenal laceraijon is a,simple lateral suiure Just as
in small bowel injuries, orient your suiure line iransversely' even il the
laceration is longiiudinal, io avoid narrowing the lumen lf the lacerairon !s
tio iono,o ""fli"""
u u"nsverse repaif withoui tension' do a longiiudinal
,li"i. it" "rtur"t""lnique
is a matter of personalpreference We usually
do a sinqle layer continuous repair in an inveriing fashion
Tne probleralic wounos are ins'de the duodonal 'oop on lhe pancrealic
aso"alt tt'" watL, wt "re
precise visualization of the laceralion is difflcult
,qs in other situations where the injured posterior wall of a struciure rs
inaccessible, consrde'openi.1g lhe ouoderLm and teo,ai5g lhe i r iury
'ron rhe irs ide. u.$:- i ' r l '1)1 'a n\aw ' t ! '1
-i-fl +r-- J^**- "'f - r'* )Protecl any ouode.1ar reparr r\ar is -ore tnan a siraigl^torward sho'r
"riur" tin"
"niit' " pytorl.
"xclusion This is good advice fof suture lines that
aie tong, nlr l t iptL, delayed' or appear tenuous Sorne surgeons
decompies. duooenal repairs etne' by a aleral dJodenostomy or Dy
"""r t ' "n, -""g*0" trbe {rom i l 'e p 'o{ imal je j ' r1Lm as parl o{ a 3_IUbe
svs'em tnat also inclLdes a gastros+omy ano a fe"d ng jeiuroslomy We
n'." i ror, in"ru ao, *o" duoienosromy br ' ' we drair al 'duoo"nal -epai 's
What if the duodenum is nearly transecled? ln the 1si' 3rd and 4th
*rts. uo., .av Oe "Ore
to ca'e{Llly debnde the duodenal war' to nea thy
;;"r;'"; t;"" do ar Fno-Io-end aiastomosrs w;th ihe verv r;-iled
mobility thai you have, it is easiest to begin sewing on the Pancreanc sLoe'
;;'ki.; t""; wav arouno the dJooenal circumlFrence trom wiLl'ir Ihe
trrn"n,-Ho*"u",, u" tt'" oLode.1a''oop' Ihe aohererce oi lhe pancreas and
the proximity of the ampulla usually preclude a duodenoduodenostorny'
The mosi versatlle reconstructive opiion for large duodenal defects rs
or i , rorrq up a RoL\-en_Y loop of ie jJnLf i lo repar lhe defpLt or lo re '
]"ru 'J i i "" . dr"o.t tu 'r1, xeeo i ' mi, .d ' nowevFr' a Rou/-er-Y'euorsirJcl ion
J,il"-"o*u.ins "td
|."levant only in a stable patient with no other active
'"Lrr'.". -Si"""
""""-. Oodenal trauma is almost always associated with
TOP XNIfE The Ari 8 Crolt of Troumo Surgery
other injuries, we use ihe Roux-ef-y technique mostly for delayedreconstructronsj veTy rafety during ihe initial opefaiion.
L * NThere.are no good damage control opiions lor a bad injury rd rha 9nd
part of the duodenum. lf you need to bail our quickly, approximare theedges of a large defect around an external drajn to convert the openduodenur. Into a controlled Jisiula. Thls should be an absolulely lasi resoft,since repairing the duodenal injLrry is always a much beiter option.
Repair inaccessible duodenal injuries from the inside
Pancreatic iniuries
What are the damage control options for injuries to the head of thepancreas? For a non-bleeding injury, the quick and simple solution isexternal drainage, converting even a major duct disrupiion into a controlledpancreatrc Jistula that has a surprisingly befign natural course.
Bleeding from a proximal pancreatic injury requires careful assessment.Once ihe pancreaiicoduodenal comptex has been mobilzed by a Kochermaneuverj cofirol bleeding by local pressure, hemostatic sutures, orpacking. Unless the entrfe pancreaticoduodenal complex is shattered,massive hemorrhage from a proximal pancreatic injury is always fronr anundeiying major vascu ar njury.
Don t fiddle with the pancreast The classic teaching is to estab|sh thepresence ol a malor pancreatic duct injury. Reality is somewhat different.lntraoperative examination ofthe lnjury wit setoom provroe an answer, andyou are aheady fanr i l iar with our lack of enthusiasm for oniablepancrealography (Chaprer 7). The truth is thai it probabty doesn t matterwhether the duct is rnlured or not because external dralnage works well in
Don't fiddle with the pancreas - drain itl
8 The Wounded Surgico Sou
Those who like playing wilh dynamite adhefe to the traditional concept
of o'pservirq palcrealic tissLe Wnal ir amoJrls Io ls perfor-lrg a
o"r i"*" : ."1"1".*" .v on a ' rormal pa,rc eal ic sl 'mp a Fig,r-rrs l
," . . , . .* i " ev.n J. ]Oer rne besi eleLl lve clrcunstarces Cons:de' 'or
example, the options for lraciure of ihe neck of the pancreas' where fie
ot"na i" tr"n"""t"a by an anteroposterior inrpact against ihe splne The
iafest definitive option for this injury is closure oJ the proximal slurnp'
followod by resecting the disial pancreas or oversewing the open drstaL
st!mp. Analomical reconsiruction would mean debridement oi the stump
."1 i*ti"g a normal so{l pancreaiic remnani into a Roux_en'Y loop of
bowel, in ciose proximity to an oversewn pancreatic head and a bowel
suture line. lf this sou nds un safe to you ' we agree Wh ile enth usiastical y
described in texibooks and often discussed, current feports oi what
surqeons actually do (as opposed to what they talk about) indicate thls
"pplo".n i" u",v *t"rv used Apparenily, enough surgeons have learned
tie oainful lesson that {iddling with the vaumatized pancreas does not pay
We prefer io close the pancreaiic stump and drain ii
Avoid pancreaticoieiunostomy for trauma
Combined injuries
Bleeo,ng pai ienls with comor,red 'niur ies to Ihe pancreas ard
a-oden.,m-oo _oI de tom a dLodenal eak lh€y ersangurrale So slop
the bleeding and bail oui l{ you can rapidly close ihe duodenum' do I
Otherwise, use a combination of external drainage and ligaiion io conlrol
Juodenal, biliary, and pancreaiic conteni Relurn for a later reconstruction
if the paiient makes lt.
Pvloric exclusion ls an effective technique fot temporarily diverting the
qast'ric "ontent
away {fonr the iniured pancfeaticoduodenal complex
i"ing e"yrot "rtg"on",
nue have a bias toward ihis elegant procedure we
i""rnl"a tro. e"otg" l- -lordan, Jr', who conceived ii We advise using t
to oroteci duodenaisutute lines in combined pancrealicoduodenal injuries
where lhe duodenum can be closed and ihe ampulla is intact
TOP KNIFE The Ad & Craft of Trourno Surgery
After repairing theduodenai injury, identifythe pylorus and make alongitudinal gastrotomyon the antefior surfaceof the antrum, close toihe pylorus. Throughthe gastrotomy, palpateihe pylor ic r ing withyour l rnger, gfasp i twith a Babcock clanrp,and pull it toward you.Ovefsew the pyloricring with a heavy (size0) suture on a largeneedle, iaking big bites.We lse a monofilamentsuture, but regardless ofthe suture maierial, the pylorus opens in 2,4 weeks.In fact, you can slaple acrossthe pylorus using a linear stapler with the sameresult,
Once the pyJorusis closed, br lng up aloop of proximajelunum and do ag a s t r o j e j u n o s t o m y .The Jast siep in theprocedure is pfovidinga route for enteralJeeding into ihejejunum. The operationis noi ulcerogenic,and vagoiomy is notpart ot it.
8 The Woundecl 5urg icol Soul
The Achilles heel of pyloric exclusion is ihe gastroenierostomy slnce Lt
cades a significant risk of nonJunction To avoid this probem' some
surgeons preJet lo do pyloric exclusion without gasiroenterostomy' relyrng
on distal enteral feeding uniil the pylorus opens
The "Ultimate Big Whack" ,vf-\
A vauma Whipple is tha ultimate big whack of abdominal trauma Use
it as a lasi resori when the pancreaticoduodenal complex is destroyed or
when the ampulla cannot be reconstrucied and no simpler solution will
work. ll is often said ihai you should consider a trauma Whipple when the
:n J1 l^as alreaoy done mosl of lhe d:ssecl ion ror you H€rein l ies 'he b g
nlrrao" ot rnis'operariol: tn" e{sangurnalirg paiierL wlh a snatterpd
i".l,".i""ar.o*a ".rp'ex
is Loo sick to curvrvF it A -tabre palient who
Jf .rru,u" n o{Ien does not need t so choose a lesser akernat 've'
however imperfeci, whenever you can'
Use pylodc exclusion to protect complicated duodenal suture lines
TOP KNTFE The Art & Croft of Troumo Slrgery
a
The three important differences between a Whipple for tfauma and alllllp,:,a'
r,arcer ar": drssecring the Lnc,nare orocess. removrrg tnegaIo|adde., and staged reconskuclion,
During the resection siage for traurna, don,t dissect the uncjnaieprocess otf the SMV and rhe SMA. Leave mosi of it adhefent to theS[,lV by dividing it piecemeal and oversewing it wilh a runnjng stitch'or he-roslas,s as yoLr proceed. Th:s greaty srmpl.fres onF ot theticky sleps of the dlsseclior.Think iwice before renroving ihe gallbladder in a trauma patieni. A fineand delicaie common bile duct may force you to use the gallbladder{orthe biliary,enteric reconshuciion.The most important difference is that a trauma Whipple is a stagedprocedure. During the jnitial damage control operation, achi-evehemosiasis and do the resection, noi the reconstrLrciion. Leave thestomach, jejunum, and parcreatic stump stapled off. Leave thecommon bile duct ligated or drained. At reoperation, perform thearasta-oses, Except Jrder the mosr,avo,abt€ circumitances. wereave thF d srdl oancreatrc siumo slapled or ovFrsew.r and do ,rotjoinit io the bowel (or 10 the stomach) io avoid a high-rjsk anastomosis ina cdticallv ill oatient.
Putting it all together
We hope you realize by now why injuries 10 ihe surgicatsoutdeserve aspecral chapter. The sirategic drmension of a soul wound isstraightfoMard, sjnce it js preity obvious from the very beginning that youmust operate In damage conirol mode and dart oui of the belJy as quickJyas you possrbiy can. The challenge of soul wounds lies in iheir tacticalcomplexity. You must simplify the taciical situation (Chapter t). Askyourself which elements of the problem can be rapidly ellminated. Look atthe deep layer of bleeding from the IVC and right renal pedicle. Do yourear'y irte4d to do a como,er vasculdr reoair or rh,s bleedrng rena'pedicleIn the context of multifocal exsanguination? Of course noi. On ihe otherhand, a swft nephrectomy wijl open ihe way to the IVC intury.
a
a
lf forced to do a hauma Whippl€ - do it in stages
Are you going to hook the pancreatic stunrp to bowel as the patLent ls
*t ino'r l "-g+t i u,r i l o{ orood? YoL rust be kiodngl A raoid dislal
pu""r"""t"atotu howeve' may enabre you to reacn lFe 'eft side of Lhe
retropancf eatic Porial vein
These examples show you how io simpli{y lactical situations- Conslantly
ask yourself whal the simplest soluiion is for a specific inJUry - and go lor
il. The only hope lor a patient with a soul wound is a surgeon who ihinks
abour liqaiion, resection, drainage' and shunting _ noi about sprral vern
grafts aid Roux_en_Y pancreaiicojejunostomles'
E The wounded Surgicol soul
T H E K E Y P O I N T S
) Soul wounds bleed lrom more ihan one vascular injLlry'
) Use the Cattell_Braasch maneuver to expose the surgical soul
) Ligation is ihe bail oui soluiion for portalveln Inlury
> Transectihe pancreas lo gain access to the portalvein contluence
) Blind clamping at the root of ihe mesenlefy ls a recipe for disaster'
) Choose your repair based on how well it fails'
) Repair inaccessible duodenal injuries irom the inside
> Don' l f iddle with the pancreas'drain i t l
) Avoid pancreaticojelunostomy for trauma
Look for wavs to simplity the tactical situation
E ,o, *",rr rn. * & croft of Troumo sursery
) Use pyjoric exclusion to prot€ct complicated duod€nal suture lines.
) if forced to do a kauma Whippl€ - do it in stag€€.
) Look for ways to simplify the tacttcat situation.
Chapter 9
Big Red & Big Blue:Abdominal Vascular Trauma
. . ,Lleon ?ntering !h? peiloneal .auit! , dpptoximalely 2lo
3 tit'erc ol blooi, bo!h liquid ond in (lols, Taere encounlerP'l
f i" ' , i"r" rcnloped. Thc bulle! pa!huaV ,uas- lhen.
idenlified as haoinB shdllereil the upPcr medial s tlo(? oJ
the ,ileen, then cntireil the refuoperitoneal area 7uh?te lherc
iii'o torB" rcttop?ritonPal hemalotna in the area of the
oanrreas.iollozuinp this, bleeding sccmed to be (ofiin3'ftotn
lhe right side,-an.l pon inspection lherc 'uas scPn Io'bi
on r*it t'o th, ight throtgh the infeioroena 'aua lhe 'e
ihtouph the supe-rior pole-of the iSht |id e!, the louer
iiiiS, A the'right iobe oi th" liui' and into lhe riSht'lateflt
b;du wilt'.. rn" infeior oena caua hole was
iiiip"a wiin a partial occlus1on clamp "' The inspection oflhe ietroperitoical arca reuealetl a huge hcthdlomo in the
midline. fhe spleen uas lhen mobilized, as uas lhe I?J1
"ilon, ond the refuopeitonedl apPtotrch wtts fiade to the
iid-iirc structutes' The paflleas 7o4s seet to be shattered
i its mid portion, bleeiling uds seefl to be cotning ftotfi the
aorta.., B'leeiling was coitrolled by finger pressurc by D,r'
Moleolm O. Peiru Llpon iden!ifintion ol this iniury' the
suterior mesmteir artery ha.l beefi sheaftd olf the aorta"'
1ii. uas rla nped wilh a'sna I l (urucd DeBakey clam p' lhe
aotta was thin occluded Tnith a straight DeBdkey clanp
above and a Potts .lafip below. At this poinl all fiaior
bleedins was (o trol led.. ' Short lv thcrcafler" ' Ihe putse
role.., 'was
found lo bc 40 and a Iew sercnds later Joutld to
be zero. No'oulse was felt in the aoltd at this time'
- Opeiative Record oI Lee Ha|ve)' Oswald'Parkland Memorial Ho spital 11' /24 /63
Cired n1t The \Nhren Commissian Repott: REart oJ the Presilent's
canmission an the Assas"^"." "f *zi,:i?::i',;X:,Til;
TOP KNIfE The Ari & Crofl ol Trourno Sugery
Operative Approach to Retropedtoneal Hematoma
No author has ever captured the tremendous challenge and un{orgiving
nature of abdominal vascular trauma better than ihis dry' technical
.".",i"" -pott 0""""t''q G To* Sn:res a,rd \is ream at Parl'aid do ng
i l rr t" * i , l 'nurpre vascLlar injJ- ies i ' l , le aodomer of Lee Hdrvey
O*"*"fa. ifr" *oon ".phasizes
lhs centralleatures of abdominalvascular
trauma: massive bleeding irom inaccessible sites' muitiple assocated
';;,;""..;; un ""u"."-tv
narrow window of oppoduniiv to save the
.lil""i. v", noi onlv see the bleeding' bui vou can also often hear it'Because
the patient is exsanguinating, you rarely have lime io summon a
more experienced colLeague to help you gain control You have lo lasten
youf seat belt and gel going.
The "lules of engagement"
An abdomlnal vascular injury presenis as free iniraperl ioneal
hemorr l 'aqe, 'elropenlo'eal lematona o' n osl co-mo1ly ' a uombi lar 'on
o{ botn. In-e'rne'cas". i l s a 'ways BIG TROUBLE a'd ine key to sLuces"
;;;p"*ry control {ollowed by a well-organized atiack The location ol
the hematoma dictates the operalive approach
Hematoma Proximalcontrol
Explore?
PenetEling Blunt
Midline res
N4idline
looping
Distal aorta/tvc
Yes SuPraceliac Matiox maneuver
Yss lnlrarenal Infrarenal aorijc
aoita or IVC exPosure or right_sided visce€l rotat on
9 Big Red & Big BlLre: Abdominol Vasctr or rrourio H
Midline suPramesocolic hematoma
All midline sLrpfamesocolichemalomas must be exPlored lf
the patieni is in shock or if You see
rapid aclive hemorrhage from the
supramesocolic area, manuall)/
compress the supfacellac aona(Chapter 2). lf ihe Patenl rs
hemodynamically siable, begrn
wlth the Maiiox maneuver' The
medialvisceral rctation allows you
to gain prcximal control of the
lowefthoracic aota bY cuiting the
lefi crus of the diaphragm(Chapier 4). Always obtain dislaL
control above ihe aortic
bifurcation because without it,
considerable back bleeding will
Iniuries to ihe patavisceral aodic segment between the celiac and ihe
renaiarteries are highly lethal They are always associated with injuries io
"ii"l".t ".ort"t.
'Blooo 'o"" '" typicary -assive confo' is not
str 'a o'r forwarO, and repair reqJires sJptac€' iac ula-ping For al these
reasins, iry to get away with a laieral repair il you can'
l l vou mJsr sew n a sy1l l^eLrc 'nte-posi l io l g 'al t yoL are obvously
racino aaainst ine rela ' ischemic l ime' ano lhe oal ienr 's chances ot
n'akin'q iiare not sreai S-"lect a \,littFd Dacron g'ail lhalis cligl"tly latge'
ir,".,i" aon" a'i."*t oecaus" the aona ol a vou.lg oaliert rr shocl< r
vasoconstricied. Since you have no alternaiive, don t hesitate to put rn a
orafi even in the presence of intestinal sPillage Thefe are no enectLvo
iumaq" conror op ons fo- thesF 'n;ur'es The patrenl s only hoPF s a
,- i . i " r i "+"" rapai 'of the aorta ano bai l out sout ions for associated
Inlunes.
Try to get away with lateral repair in suprarenal ao*ic iniuries
TOP KNIFE The Al-t & Crofl of Troumo Surgery
Pentrating trauma to ihe proximal fenal artery is essentially a side-holein the aorta. Initia control and exposure are the same as previouslydescribed above. The realistic options for definilive repair or damageconhol of the renal vessels were described jn Chapter 7.
Injury to lhe cel iac axis or l ts branches is uncommon, but deadly.Typically, you see a gastric injury with either an expanding hematonrabehind the stomach of brisk aftefal bleeding from behind and above iheesser curve. This is one of ihe toughest and least advertised sltuations inabdominaltrauma.
Wh le you car gainproximal control of thecel iac axis by rnedialvisceral roiation, this wilnot help yo! see orcontrol bleeding lrom itsbranches. Furthermor-o,the operal /ve circum-siances may force you toattack the bleeder fronfthe front. There are noslandard prepackagedsolulions for this d tficulis i lLrat ion. A lechniquethat has worked for us isinserting a gross hemo-staiic stitch wiih a heavysuture on a big needle (such as siz€ 0 polypropylene) into the lesseromentum above the lesser curve of the stomach and suturing unti thebleedjng stops.
A useful allernatlve is transeciing the stomach by firing a inear cuitngsiapler across the body, giving you immedlaie access to the vasculaf injurybehind ii. lf the patient suryives, complete the hemigask€ctomy aireoperation. Dissecting oui the origin of the celac axis, encased in a thicklayer of pefiaortic tissue, is not a realistic oplion in a bleedlng patient.
9 Bls Red & Bis Bluer AbdomjnoL vosculor lraur'o E|
IntLry Io tne p o\rmal SMA 15 anothe unlo-giv'ng s;t'iafon tnat prelpnis
," ' : ' ; : ; " " ; ' ; -" ' "col ic .ematomd An ir jLry to 'he sMA dbove lhe
""*r"* J *""*'",'t
"n anterior hole in the suprarenal aorta Control I
iror tt'" t"t "ia"
Uy p"*orming a Mattox maneuver and clamplng the aorta
"0""" *J oa"* ,i" t"le-off o-f the vessel You can then get to the injured
SL4A, either from the side orfront, by making a hole in the lesser oment!m
and retracting the upper border of the pancreas caudally These injuries
are tvpicallv a=ssociated wiih damage lo the pancreas and adjacent bowel
Ott"'n your b""t option *ith a proximal SMA injufy is ligation' followed by
retrograde reconsiruction
Control of bleeding from the reiropancreauc SMA is achieved by
dividing the pancreas (Chapter 8) An injury to the SMA below ihe
parcre-as will manifest as a large her'atoma at the root of the mesentery
The damage control opiion for S[4A injuries is insert ng a tenrpofary
"lrnt. Wt it"i"" t'"u. not done it, others have reported it wofked {orthem
t ioari,rq t're proximal SIVIA i_ a sFverery hypotelsive ano vasoco,rslicted
p."t,"nt:. noi "
gooa op ro' oecaJsF il lFaos -o bowel iscl-e-id So \ow
should you reconslruct lhe SIVIA?
The pinciples are lo use
the most exPedient method
and stay away from the injuredpancreas, because a €aKrngpancteas and an anerlalsulure l ine don t sr i welL
together To do a retrograde
reconsvuction from lhe infra'
mesocolic aorta, J/ou need
access to the side or to iheposierior aspect or tne
vessel, You can approacn fie
SIMA immediately below thepancreas and frori the left b)/
dividing the liganrent of Treitz
and mobiLizing the four ih
portion of the duodenum.
TOP KNIFE Ihe Ad & Croft of Troumo Surgery
Alternativey, do a full Caiie lBraasch maneuver and reflect ihe small
bowel upward lo obtain good access to the posterior aspect of the SMA
lf you aie not sure how to do it, you can dissect out a more disial (and
therefore smaller) segment of the SlvlA at the base of the mesentery
Reconstruct the injured SIMA using a 6mm ringed ePTFE graft ftom the
distal aoria or the right com..on liac ariery LJsing the latter has
advantages: it does not require aodic clamping, is easy to cover wrh
omentum, and is technically staightlorward
Reconstruct the SMA away from the iniured pancreas
Midline inf ramesocolic hematoma
Eviscerate the smallbowel to the dght, Pull lhe
transverse colon uPward,and take a good look ailhe
retroperiioneal hematomawaiilng n the shadows ll
the bulk ofihe hemaioma is
to ihe Left of ihe small
bowel mesentery, Youprobably are dealing wiih
an infrarenal aodic injury
thai can be approachedlhrough the midl ine l t ,however, ihe hemator.a lsmore to the right, Pushingon the ascending colonlfonr behind, you probabLy are dealing wrth an IVC injury and
right-slded medial vlsceraL rotairon.
should do a
Aooroach an inlramesocolic aortic injury as you wouJd a ruplured aortic
aneurysm. lf you have tme, place a self'retaining retractor and ofganize
the o;erative field lo keep the bowel evisceraied and out of vour way The
9 Biq Red & Blg BIue: Abdomino VoscuLarrroumo g
classic pitfall ln proxirnal conirol
o{ lhe infrarenal aorla rs
iatrogenic iniury to the LRV or
lVC. To avoid ii, look at ihe
shape and Pfecise locatlon ol
the hematoma. ls ii distal, away
from the root of the transverse
mesocolon? lf so' ihe 'sk ol
inadverieni injury to the LRV is
small. Mobilize ihe ligament of
Treiiz, refleci ihe fourth poriion
o{ the duodenum lalerally, and
enter the safe Pedaodic Plane'Blunily cfeate a space lor a
clamp on boih sides oi the aorta
using Your {ingers However, if
the hematoma exlends higher uP
obscuring ihe ligament of Treilz'
it will be much safer io gain
supraceliac control ihrough the
Lesser omeniurn above the stomach, elther by man!ally compresslrg lne
".,t" "g"ln"t the spine or by clamping through the tighi crus ot the
diaphragm (Chapter 2).
Wlth proximal conirol in pLace' enter the hernatoma and' using blunt
ai"""iiiJn, ".t"turrv
oti"nt yourselJ to avoid the LRV Dlsseci distally in the
."r-""nt "f"*
to a"tin"it'" injLrry' Reposition your clamps below the
i*Jlrt"r,"" to "onttot
tfoublesome back bleeding from lhe distal aoria or
tom 'he lLmbar afe'es ard oeg n lhe reoa I
lJn{odunateLy, we cannot of{er you good damage conirol optlons lor the
infrarenal aorta either' We have lried inserting a chest iube as a lemporary
"tluniin ""t,"*" "irrutlons but did not have a survivor' However' in 1945'
C.i. Hotr", ot Cin"innuii brldged a large abdominal aortic de{eci {rom a
-eware of iahogenic vein injury in an inframesocolic hematoma
TOP KNIFE The Art & Crofl of Trourno surgery
gunshoi wound with a vltallium tube secured wiih umbilical iape Thepatient survived and went home with the tube in place Anolher desperatemeasure for extreme situaiions is oversewing ihe injured infrarenal aortaand bilateralfasciotom es, followed by extra_anatomical revascu larizat on if
the paiieni survives the physiological insu t.
Whai are the definitive repair options? Unless the laceration is smalland amenable to simple lateral repair, your besi bel is io grab ihe bu I bythe horns and insert a short 14-18mm synthetc nterpositior gfaft Since
lhe aoria of healthy young paiients is smal and iears easily, at(empts losew in a patch or do an end{o-end anastomosis olten ead io anunsaiisfaciory result. We advise yoLr save yo!rself grief and go djfectly forgraft interposlion using knitted Dacron.
Always cover your inframesocolic vascular suture lines with omenium
Our preferred technique is lo lake down lhe greater omentum lrom the
tranverse colon along the bloodless line, create an opening in the
lransverse r.esocolon to the efi ol the midd e colc artery, and swing themobi ized omenlum through ihis hole into ihe inframesoco ic compartmentto cover ihe aortic reconsiruciior.
l f you see a bleeding hole in the psoas muscle, BEWAREI This
deceptive y simple lnjury ls one of those traps not mentioned in the books.
Whatevef you do, don't dig into the muscle in seafch of the source
B eeding in these cases ofien orig nates from the ascending umbar vein
or a lur.bar adery. Think of it uoi as a sma I bleeder inside a muscle, bui
asan naccessible sdehole in ihe aorta orthe lVC lnsiead of a direct
aitack, choose another hemostatic iechnique: stufi ihe hole wiih a localhemostaiic agent, pui a balloon catheter into it, or pack t with gauze.
Whatevef you do - don t try to ideniify the bleeder' Your small bleeder wil
rapidly bloom into a ful-scale catastfophe.
Don't chase a bleeder into the psoas muscle
I8 ig Red & Big Blue: Abdtt t t 'ut ' t ' t ' ' ' t " t E
The Infedor Vena Cava
A large dark hematoma
behind ihe right colon is a
€ign o{ IVC iniury. This is a
unique sitllation in ttauma
surgery whefe you may
deliberately flip a control|edsituation into unconirolledcalamity. The iamponadeef{ect of the retroPeritoneurnmay have stopped rne
bleeding, and }/ou are going
lo unroof the injury and
release the tamPonade, with
a real risk of making thrngs
much worse. You betler be
absoluiely sure You Know
what you're doing
I
\
Prepare for BIG TROUBLE(Chapter 2), and ihen unroot
the hemaioma bY right-sided
medial v isceral rotat ion.
Once you afe greeted with a
violent gllsh of dark blood,
gain temporary control oY
digi tal ly comPressing the
IVC againsi the splne aDove
and below the injurY. RaPidlY
delegate the iob to Yourassistani io free Your hands
fof the repair. Digilal Pressureis effeciive, but the assistant's
hands limit Your worK sPace
We pteief to use t ighi lY
rol led laparotomy Pads held
on ringed clamps Watch ihe
TOP KNIFE The Art & Crofl of Trourno Sugery
palient's blood pressure on the monitor, and talk to the anesthesiologist lf
the patieni crashes wh le lhe lVC is being controlled, compress the aoriaas a hemodvnamic adiunct.
The key maneuver inrepairing large veins is todefine the edges ol rhelaceration. lt js mpos-sible to see the injurypropery wh le the IVC lsactively bleeding. You arelooking for the edge ofthe Laceralion - if not allo{it, at east part of it. Lookfor ihe s very intima andgenily gfasp the edge ofthe laceraton with a onghemostat or a Babcockclamp and lift it up tovisual ize the adjacentsegment. Apply anotherclamp and hold it up too.As you systematicaly workyour way around, you wlllbe ableto definethe entire circumfefence ofthe aceration and then controlit with one or two vascular clanrps. A side-bting Satinsky clamp isparticularly useful.
Another lrick is to insert a polypropylene suiure ai ether end of thelaceral ion and t ie i t whie your f inger occludes the hole. Gent ly pul ingthese end sutures caudad and cephalad, respectivey, pulls the edges ofthe ve n iniury taut, like a rubber band or ihe sif ng oJ a fiddle. Moving youfocc uding finger slowly allows you to place one suture at a tlrne in are atively bloodless field. Before you know lt, the repair is complete.
lf the IVC injury is posterior, inaccessibe, or there are severallaceraiions, delining ihe edges is much more difficult. When you can see
9 Blg Red & Big Bluei Abclomlnol vasculor lroumo g
tne b.€eoi'1g ']ole bui ca11ol delile the edge or cannot apoly d slde-bililg
clarp, 'n.e-rng a ld 'ge Folev catnercr rwi lh a 3omlbal loo,1r r '1 lo t \F lJmpn
and inflating it can helP.
A hematoma behind or above ihe duodenal loop should warn you ot a
caval injury around or above the renal veins lnserl a long Deaver retfactor
over the inferior surlace of the liver and iow ln to compress Ine
inaccessibLe supfarenal lVC, while simultaneously reiracting the liver 10
or*ia" "
fl.it"O wofk space Expose lhe right lateral and posterior
!"0""o oi tf'" pafarenal IVC by mobilizing the tighi kidney medially
Similarly, you can divide ihe proximal LRV wiih impuniiy to improve access
to ttre titt siae ot tle tVC. Ev€n with these maneuvers' conitol of the IVC
ai or above ihe renalveins is a real technlcal challenge
In IVC trauma, get hold of the wound edges
What are yout repair opiions? lf the laceraiion is straightforward and
easily accessible, do a latetal repair' lf ihe injury requlres a complex reparri
the patient is stable, and you have the necessary experience' you may be
rempled to e'gdge i l gymnast lcs Unlo4urately ' -hs favorab'e
""rno'- ,- . ' " "" .pf"" , r* f in i ' r 'y i r a stabre pal iel l wi lh no olher
iniuri"" i" "n
extremely rare bird, almosi never seen in natufe A classic
eia.ple of gy.na.t 'c i , an r l lJsrrai ion yoJ of ien see in boons a1d at lases'
' " r"p; , oi , f ' " posier io 'wa' ol th. IVC fro- Ih€ Inside tn 'oJqh a
tonoiiudinal anierio, venotomy Nlany oiher neat complex reconstructive
t;;"iqr"" n"* been described for high-grade caval iniuries' including
Dane ora{'s, svnlhelrc grahs' palches ard n'ore Allbelorq to a bra"cn ol
i r ' r" i r* ." ' . t "*"* l ' " .w'r as scielce' icton Thev rdy nave worked fol
someone somewhere, bui ihey ate not going to wotk for you Our strong
advice - and we cannot ovefemphasize this enough ' is to avoid the lancy
stu{f. lf you cannot do a simple lat€ral repaif on the inlrarenal IVC' ligate iiL
Do your besi to repair ihe actively bleeding suprarenalcava' but i{ the
oaient is,n exlremrs, consder a baloul solur lo ' Pacl ' 'ng may work _ l l
nas cerlainly wo-ked lo' us L:gat:on is a,rotl^er ootror' accept:ng that ihe
kidneys maytake a hii' which is stillfar betterlhan on_iable exsang!lnalon
TOP KNIFE The Ari & Croii oi Troumo Surgery
More importantly, if you see a non_expanding supfarenal henratoma below
the liver. do not touch it. Leave it alone ot pack it Don'i poke a skunk.
Ligate the IVC if lateral repair doesn't work
Pelvic hematoma
lJfless you specifically suspeci an iliac vascular inlury, do not oper a
pelvlc hematoma in a bluni ttauma patent wilh a pelvc lracture You w ll
only make matters wofse. lf you tind yourself Jacing a rupiured pelvc
hematoma in such a patient, your best move is to quickly pack the pe vis,
which shou d control venous bleeders. Fo low th s with a tapid ter.pofary
abdor. inaL cosure and proceed to angiography fof selectve embol izat ion
of aderial bLeeders, typ cally sma I branches of lhe iniernal liac arieties.
In a patient with penetratingt|auma, a pelvLc nemalomameans injury to an iiac vesselunless proven otherwise. Youmust unroof the lnjury and flxit. lf the injury is on lhe right,mobillze the cecum; lf on ihelef l , mobi l lze the s gnroid.When you can t be sure andsuspect a bi lateral in juty,doing a full Cattel-Braaschmaneuver grves you wdeexposure of the illac vesseLsand keeps al l your opi ionsopen, Now you musi gain
controL of the pelvlc vessels.Pfoximal conirol is obviouslynot enough. You maY haveforgotten the ntenral i iac
9 Big Recl & Big BLue: Abclomhol vosculor lralmo g
vessels, but they have not {orgotten you, and ihey afe difficult to reach So
what should You do?
The technica! PrinclPle is
"walking the clar iPs '
Begin with global control In
virgin terriiory outside ihehematoma by clamPing theproximal common l l racartery iogeiher with iheunderlying vein. The easieslway to achieve dLstalconlrol is to have ] /oufassistani tow in wilh a large
Deaver retractor over thelower part of the oPenlaparotomy wound, globally
compressing the exiernali l iac vessels wi ih ihereiracior against ihe Pubicbone. Now, oPen the
poste-:or aodonila ot oelvic periloiFun' and o''l1lly d ss€ct w th yoLr
inoe, ro q"t Io ll'e lace atpd vessel As you progress i']sidF the
heilatoma, advance the clamps closer and closer to ihe iniury' applyrng
if'"r-a U.,i' iliac artery and vein lniiially, your conirol is global and
,"mot.. e" you gradually converge on the source of bleeding proximally
"nJ ilturrv,'vor i
"rut ping becomes more seleciive Finallv' isolate and
controLthe internal iliac ariery or vein using an angled lascular cLamp' a
Satinksy side-biting clamp, an intralurninal Fogariy balloon' of any olher
method that works fof J/ou
Walking the clamps is a generallechnica princlple that applles in any
situation ihere an injured artery bifurcates and the deep branch is eithef
not oirec.tv v-be oi i raccessrb,e Conrro o"ne blFedi,rg 'e-ora'anery
" *" o'oi", td'oiid iri|.ries ir ihe lecl and pe,relralrrg lra'rma -o Lhe
tnorac; out lel are obvroLs examples wnerF wa ' ( 'ng 'he ula-ps can save
the day - and Your Patient's llfe
With irauma to the aortic or caval bifurcaiion or when you cannot be
sure which side is bleeding, you may have lo do a ioial pelvic vascular
TOP KNIFE lhe Art & CroJl ol Troumo Surgery
isolaiion. Begin wth the Cattell-Braasch maneuver to obiain ihe wdesipossib e exposure of the pelvlc vasculature, then proceed wiih clamp ng(or compressng) the disia aorta, and insert two Deaver retractors tocompress both dlstal exiefnal iliac arteres and veins. Now, enter thehematoma afd start walking the clamps io converge on the inj!ries _ Jirsi
on one side and lhen on the other. Keep in nrind lhai the ureter passes
over the bilurcalion of the common iliac artery, and vour paiieni wi I do somuch better without a transected Lrreler.
Walk the clamps to gradually converge on an iliac iniury
Traunra io ihe confluenceol the common i iac veinsis part cular ly dffcul t ioconiro because i t isinaccessible, Lying beh ndthe r ight common l l iacartery. Lf you cannot get toi to inserl a hemostatcsuture, your besl move !sto i ransect the overyrngright common i iac aderybetween clamps, giv ngyou access to the injuredconf luence. l f the pat ientsurvives, repair the tran-sected artery or Insert a
What are your repair optlons for the iLiac vessels? By the iime you havegained vascllar control, ihe patient has iypicaly suffered riassve bood
oss and has associaied iniuries to olher abdomina otgans, usually ihe
co on. bladder or small bowel. Talk io the anesthesio og sl and assess lhe
magniiude of the physiological jnsult. More olten than noi, the siiuation wil
have damage contro wrltten alL over 1. lf the artety requ res on y a simple
l a l " ' a ' e p a ' - j - s _ o o i . . l f r h e i _ j u r y i s m o ' e e n e n s v p a t e - p o r c r y s l ' u 1 l
is a classic and effeciive ba I oui ootion.
9 Big Red & Big B ue: Abdominol Voscu or lroumo n
Anolher allernatlve ls to oversew the lniufed iliao a ery pedorm a
i"""i"i".V, ""a
*""f, ,le leg in the Surgical Intensive Care Unit (SlClJ)
lfthe patieni survives and the leg is grossly ischenric' do a femorojemoral
l*u"'" ior"a,or" p"*r"ion lf the patient is too u nstable even for a trip lo
iiJ on, ti'i" "t'uigttf.'*ard
bvpass can be done ai the bedside in SlcU
it "
togi"ti"" ""ni"
u iltLe demanding and the conditions awkward' but
the operation is feasible and we have done it Another uselul damage
contfol tech nique is to insed a Foley balloon catheter inio a bleeding bullet
tract deep in tire pelvis lo control hemoffhage lrom ihe iniernal lliac
ierriiory that is not accessible to direct control
As for definitive reconstruction of an injured iliac artery' our advrce s
not to wasie valuable tlme irying to mobilize a iransected artery ror an
end-to-end repair because i t rarely works lnstead' just Inierpose a
synthetic graft.
SpilLage of lniestinalconient is very cor.lmon in iliac vasculaftrauma and
po""s o dle --a b"car-e i r te" l i ' ra cor lel l a1d -yr lh"r ic grdtts a'e roi a
lood "o-on"ton
Tl- is s n fdct sJch a oopuar qJPsl lo, t on Boa'd
ixams that you are lit<ely io encounier it there befofe you face the situation
in the OR.'Whal should you do? For lhe Board examiners' ihe safest
answ"r is ulso your sufest;piion: ligate the artery and do afemoro_{emoral
bvoass a{ter the abdomen is closed However' in real li{e we assess the
deqree of contamination For limited spillage of small bowel content' t Ls
..i to fix the bowel, nrigate the area, insert a synthetic interposition graft
and cover ii wth onrentum. lf the injufed iliac artery ls swimming In a pooL
lf fecal materlal, it doesn't iake a Google search to {igure out ihat ligaiion
with extra-anatomic bypass ls the only realistic oplion
Do not dilly-dally wiih iliac vein injuries They afe extremely unforgiving
and leihal. 1l iou have controlled the bleeding and youf paiient ls still alive'
uo, l"* ar*ay *"a up a pretty large chunk of good fortune Don t spoil' "u"ru1n
no 6v 6i1"rnpr ' .q compler -ep€i s l l yoL can l i / l , le inj- 'v wth a
., :0" " i " ' r f
,epai ' . do i t . l { no' . ,gd.e tr-a vFir wi l r 'oLI a rno-enl 's
hesliation The iliac veins are nol mobile, so trying to close a large deteci
can put tne repair unaer tersion You find yo!rself replacing one small hole
wiih two larger ones. The nexi bite of the needle converis lhis into lour
S ,o, *n,r, ,n. on & croft or Troumo surgery
hol€s, and before you know it,1he game isover - you've lost. The gmartestmovs you can make is ligate lhe vein,
Shunting aRd li$lion ar€ the bail out options for iliac artery iniury
) Try to get away with lateral repair in suprarenal aortic injuri€s.
) Reconstruct the SIV1A away from lho injured pancreas.
) Beware of iahogenic vein injury in an inframosocolic h€matoma,
.) . .Don't chase a bleeder into th€ psoas muscla.
). h NC tr.auma, g6t hold of the wound edges.
) Ligate the IVG if lat€ral r€pair doesn't.work.
) Wdk ihe clamps to gradually converge on an iliac injury
> Shunting and ligation are th€ bail out opiions for iliac art€ry injury.
Chapter 10
Double JeoPardY:Thoracoabdominal Injuries
A battle is a Pheflorfienofl that alu)ays htkes
place ifi the i nctiorr between tTDo 'naps'
- AnonYmous Bdtish Officer' 1914
Where to go {irst - belly or chesi?
You are in ihe OR preparing to opefate on a 17_year_old kld in severe
shock. Hls story is very {amlliar: he was walking down ihe street mLndrng
his own business when two dudes approached and shoi him in the left
chesi. These same iwo dudes pop up fegularly on the stfeeis (especially
on weekend nighis), shooting people who always claim ihey were just
minding their o;n business Plain x'rays of ihe chest and abdomen show
a bullei in the epigastrium so, lhe buLlet went inio the Left chest' across
the diaphragm, and into ihe abdomen The chest iube you inseded on ihe
left is acliv;ly draining blood, while the abdomen is getting noiiceabLy
distended, and the blood pressure is plummeiing Where do you begin?
Chest or belly?
The clock ls ticking, and yout patieni is bleeding Belly or chest?
lf you are unsure where to begln, you are noi alone Some ot the mosi
exasperatlng baitles in trauma surgery occur in the iunction between the
abdomen and chest Duf lng training you are l ikely to hear about
thoracoabdominal iniuries at morbidily and mortallty conferences' bul
when you try to ook them up in trauma texts, you are in for a small
surpr ise. There is not a single chapter on thoracoabdominaltrauma in any
cur;ent major irauma iexlbook Why? What exactly are thoracoabdomrnal
injuries? Whai makes ihenr so special?
TOP KNIfE The Art & Croft of Troumo Surgery
A tour of no-man's land
The thoracoabdominal region, also known as the inhathoracicabdomen, is a unique anatomical region. lt extends from the coslal marginup to the nippie l;ne anteriorly, 6th intercostal space laterally, and the tip ofthe scapula posteriorly. The region includes abdominal and thoracicorgans on both sides of the diaphragm.
Five visceral comparlments converge in the thoracoabdominal region:the ghi and Ieft pleural spaces, mediasiinum, upper peritoneal cavity, andupper retroperitoneum. While you are working in one compartment, lots ofmischief can occur in another, A common scenario has ihe surgeon andeniire OR team focusing on the iniiiajly selected compartmeni whileneglecting the others. Rem6mber also, th6 abdominal side of thethoracoabdominal region contains th€ leasi accessible portions of iheaorta, lVC, and upper Gl tract.
Five compartments converge in the thoracoabdominal region
lO DoubLe Jeopordv: Thorocoobdomino tr"*' E|
Strategic considerations
Approximately two'th tds of patienls with penetrating thoracoabdominal
,",rr|"; "t" "r**"t'V
managed by chest tube drainaqe followed by
i.i;";; i;; bparoscopv) Roushlv one-ihird will need operative
iiiJ*""ii"'" l" notr', "r,"",
and abdomen' and it is in these patients that the
traps awaii ]/ou
Thoracoabdominal injuries are ihe most comman lotn ol multicavitary
*""" l ; ; : ; ; " ; " ;e dearrs win b' |eeoins i r -ore Ihar one visceral
:l:ilu.:n;:":31,i^"L1".jlllifi;,""]ii";J##:iJiiT""
IoL"" - r*gf, you have an assortment* ' ,ala" p-" '"t gut wl_en tne patenl rs breeoilq lrom seve'al soLrces
"i."n.",1"*'r, you are not nearly as €fiective Why? Because lhe
;;";;joil;ii;Jt is sreatl;, accelerated Multiple soufces o{ bleedins
'*i: "im ;:ru.*" ", """"-"""1j lllfJJffi"::l"Ji: ij:
,r""t o' i"t ' , t '" th" ope'atve leld Lots ol worn to do: rol enough I 'ne
il J i. vo, .u"t O."lae very quickly io switch to damage contro mooe
How early can You make the decision?
You may be suPrised to
Learn that the trajeciory oJ
ihe bullet can help ]/ou make
an early decision to bail out
A bullei trajectory acro$ ihe
iruncal midline in a hYPo_
tensive Patieni ls a very
ominous sqn because ine
major neurovascular bundle
ol the human body (aorla'
vena cava, and splne) ls a
midline struciure Therefore,
the likelihood of a major
cardiovasculat injurY is high
and so is the modalrty A
trajectory across lne
TOP KNIFE The A.t & Crott of Troumo Surgery
ihoracoabdomina/ mid ne in a hypotensive patlent shoutd pui damagecontrol (and the possibility oJ a cardiac injury) foremost on your rnind, evenoelore you make the ncision. We cal a bullet trajectory across ihe iruncalmldine a transaxial injury.
In a thoracoabdomtnal gunshoi injury, ihe bu lei has an /mporiant storyio tell, which is why surgeons with experence ir peneirating trauma obtaina p aif film ofthe chest afd abdomen, if possjble, before going to the OR.These radiographs, with metal markers placed adjaceft io eniry and exitwounds, iellyou what to expect and guide you where io go.
Every bullet teils a story
Which cavity first?
Whe/r irying to decide whether io open the abdomen or chest frrst, youface one of the classic diemmas of trauma surgery, and there aren t anygood rules to help you. Even with a lot oftraunra experience, you wlllbeginwith the /ess urgent cavrty in about oreihird of ihe cases, mainly becausethe chest tube output is lrequently misleading. In some patients, the chesitube outpui actually feflects intfa-abdomina hemorrhage entering thechest through a hole in the diaphragm. In others, a misplaced, kinked, ornor{unctionrng chesi iube creales a {alse rrnpressiof that the patient is nolofger bleeding. Here are some guidelires io help you decide where to go
a Be paranoid aboui chest iube ouiput, ii wi ofief ead you astray.Assign a specifcteam memberto mon tof t throughout the operat ion.
a After chesi lube insertiof, get a chest x-ray in the ER to see if thedrained side of the chest has indeed been evacuated.
t Have a high ndex of susprcon for peficardtaltamponade.a lJse focused ultrasoLrnd (FAST). Despite obvious Ilmitatlons, the
FAST exanrination wil ofien tellyou ifthere is a pericardialtampofadeor ots of blood in the belly.
a Play the odds. ln a right-sided ihoracoabdominal peneiration, themosi likely source of hemorrhage js ihe liver, so beginning with alaparotomy is often a good decision.
lO Double Jeoparclv: Thorocoa bdomlnoL hr!r es El
The most impodant advice we can ofler you is to maintain lactLcal
*"lUi|',r". Si"l"t"" show that you will o{ien begin in one caviiy while the
main source of bleeding is in another' Recognize this fact and compensale_o, i , u, o" i_q vigi lani ano rac.rca y l le/b' AuL'vely seFk cl res I l_al
so-" 'n ng susio ou. ,s ndpPen ng o' l lhe other s 'de ol Ih ' didp' tagm l ' re
a qraoLaJy pro'r t roi ' rg ,renioiapn ag oroore'srve'y obsuu'r '19 your
ooe".a'ue'r . ld. A,ways oo p'epared ro cl 'arge yoJ'pra- rr ' id_operator
a;d rapidLy dive into ihe other side of the diaphragm
Here again, good team leadership comes lnto play Talk io the
anesthesioLogisi Often a subiLe physlological derangemenl of
lnconsistenct ls the only clue that hemorrhage is ongoing on lhe other s de
o{ ihe diaphragm
clues to Bleeding on lhe Other side of the Diaphragm
Unexplained hYPotensionInappropriaie response to lV fluids or blood
Graiuai in"reas" ln air*ay pressures (sign of a hemo/pneumoihorax)
Elevated central venous pressure (sign of lamponade)
Maintain tactical f lexibility
Peeking into the Pericardium
lf you suspecl a Perlcardiata..ponade during laParotomY,
ihe quickesi way io find oui rs
by doing a transdiaphragr.aticpeicardioiomy. Begin bY
d viding ihe lef t l r iang! larlgament io mobi l ize the lei l
lateral Lobe of ihe liver, whrch
usualy can be folded upon
ilsel{ and retracted to ihe
right. ldentify ihe diaphragmin the mldline, anierior to the
TOP KNIFE lhe Art & Crof l of Troumo SLrrge./
EG junction, and grasp lt with lwo Allis cLamps Be careful not to iniure the
phrenic vein. Incise the diaphragm and the overlylng pericardium between
the Allis clamps unlil you see fluld escaping {rom lhe pericardial sac lf the
fluid is cleaf, close the hole wiih a heavy monofllamenl suture ll it is
bloody, pfoceed with either medlan sternotomy or lefl anlerior thoracotomy
(Chapter 1 1).
Mobilize the left lateral lobe for transdiaph.agmatic pericardiotomy
Fixing the diaphragm
Use laparoscopy io dlagnose a diaphragr.atic injury in asymptomaiic
patients wth thoracoabdominal penetraiions Lapafoscopy is an excellent
way lo look for iniuries io the left diaphragm or anterior portion ot the rLght
dlaphragm. l{ ihe paiient doesn't have a funciioning chest tube on the
relevant side, insufflating the belly may cause a tension pneumothorax if
there is a hole in lhe diaphragm. Therefote, prep and drape ihe chesi and
abdomen, and have a chest iube lnsertion klt ready before you begln
insuff lating the peritoneaL caviiy
Wiih an adequate pneumoperltoneLlm and the paiient t lted head up,
you have a nice view of ihe left side oJ ihe diaphragm and a partral
(anterior) view of ihe right. l{ ihere is a diaphragmtic iniury proceed with
explofaiory lapatotomy because you can t rely on laparoscopy 10 ru e ouT
a ho low organ injury Some surgeons repait lhe diaphragm
lapafoscopically if lhere has been an interval of several hours irom Lnjury
and ihe palient has remained asymptomatc.
Repair of an acuie diaphragmatic aceration s !sualy sttaighifo|ward'
lf ihere is a herniated organ ln the chest, reduce il' and see i{ ii is
perforaled. lf you are having diffcuLiy reducing the hernia' incise the
dlaphragm to enlarge the defect a Liitle to solve your ptoblem When you
are ready to cose the laceraiion, grab the edges with long Allis clamps
and pull ihem toward you. Use a cean sucker to evacuaie the pleural or
pericardial space above the injury Look at ihe effluent in the suctLon
lo Double Jeopordv: Thorocoabdomrnol hluies El
tubing, ls t clear or can
you iell what the Patienthad for supper? lt the
chest is heavily contam_
inaied, or f You are
evacuaiing lois of blood
and clot, formally open the
chest to address the
oleural space directly
Wilh heavy contamtnalpno{ the pLeuralspace, trying
to clean the hemiihorax
through the diaPhragmaticdefect is keyhole surgety
It is unsafe and ineffective- don t do rt.
Close ihe diaphragmaticlaceration wrih a non_
absorbable heavy suture
We Lrse a running suture for
short lacerations and slmple
inierrupied suiures for long
ones. some surgeons preler
horizontal matlress sutures
or even a twolayer repair.
An impodani technicalprinciple is to leava the ends
oJ every suture long and use
them as handles io Pull lhe
diaphragmatic de{ect ioward
you. The edges ot a d|a_
ohraomatic de{ect tend io
,nue,i, so p.rffing o" Lhe last sntch wher placing lhe ne'l ore will l-elp you
^"t':""" oooo a'ppos'tron Take large oites Lo preven breedirg from t5e
pl'ren'c Jessers or ihe p eJra sioe of lhe diaol_raqm
TOP KNIFE The Aar & Croft ol Traurno Surgery
What if the defect is large and you cafnot approxlmate it wiih a simplesuture? lf the diaphragm s avLrlsed peripheraly, as sometimes seen insevere bluni trauma, and the paiient is stable, you may be ab e to realtachthe avulsed diaphragm to a rib, usuaLly 1-2 ribs above the eveL of theoriginal avulsion. When reattachment s not an option and ihe defect is ioolarge for primary repair, a non-absorbable pfosihetic mesh is a quick andeasy sotulton,
lf you have to bail out or the operative field ls heavily contaminated,reconstruciion with synthetic non-absorbabe mesh is not an oplion. Whilethere is no compelling reason to close a large diaphragmaiic defect whenoperating in damage controlr.ode, failureto do so willlorce you to dealwlthan even arger defect at reoperation. The muscular edges of the defecirapidly reiraci, progressively enlarglng ihe gap. Preventthis from happeningby insertrng an absorbable mesh as a temporary physica barrief betweenthe abdomen and chesl. At reoperaion, if the field is clean, the absorbablemesh can be replaced by a permanenl non-absorbable prosthosls.
When fixing the diaphragm, pull it toward you
Opening Pandora's Box
Thirk iwice (and possiblyihree times) before decidingio mobi l ize the l iver in apai ieni with a thoraco-abdom nal ifjury. You may beblowing the ld off Pandora'sBox. A patient wiih a right-sided thoracoabdominal injurydrain ng large amounts ofdark bood from a rnediahole in the d aphragm s l ikelyto have a retrohepatic venousifjury draining nto the chestihrough lhe diaphragmaticdefect. Going into the
lO Doube Jeopordy: Thoracoobdominol ","'t' E
abdomen to mobilize the liver and iix ihe hole from below is a lethal
mistake. lf indeed you are dealing with a coniained retrohepairc caval
rnrurv. lorl w J rose containment. converling lre slluallon inro unconi'o'led
venor,. h".orrh"g" Very rapidly you wi| i nd yoJrsell ttyirg to sqLeeTe
the toothpaste back into the tube
The correct approach is notio mobilizo the liver and stay wellawayfrom
the bare area. lnslead, return to ihe chesi and simply close the postenor
diaphragmatic hole with a couple of big siitches This simpl€ soLution will
re-establish containment, keep Pandora s Box closed, and prevent the
caiastrophic hemorrhage
Never open Pandora's Boxl
)
)
)
T H E K E Y P O I N T S
Five compaitments converge ln ihe thoracoabdominal region
Every bullet ie ls a story
Maintain iactical {lexibility
L4obilize the leit laieral lobe for tfansdiaphragmatic peticardiotomy
When -rxing lhe diaohrag-, pu I t loward you
Nev6r open Pandota's Boxl
TOP KNIfE The Ad a Crof l of Troumo Surgery
Chapter 11
The No-nonsenseTrauma ThoracotomY
Life is pleasaflt Death is peacefulIt's the fuansitiolr that's ttoublesome.
- Isaac Asimov
lmagine playing a new computer game The plot takes place In one or
more i tve do.ains o|. terrltories While you're erpLoring one domain' the
real action may well be unfolding in anothef' Each domain has a separate
portal, and choosing ihe wrong portal for a speciiic game lands you in deep
iroublefrom the get-go. To make things even more inter€sting, ihe game has
a different storyline in each terdiory. To top everythlng, your game rs last_
paced and short ' with no teplays
Beginning io think that you don't wani to play? Sorry' ii s noi a game'
and you have no choice lts thoracotomy for trauma, an operation that
olien starts as a good case and quickLy iurns into an operatlve roller
coasier, especlally if you are a general surgeon who does not frequenlly
visit the chesi. The action can unfold in one of more of iive separaie
viscefal compartments {two pleura! spaces' peticardial space' thoraclc
outLet, and posierior mediastinum), each accessible through a difiefent
incision. Several pathophysiological mechanisms may be at work
simultaneously: bleeding, hypoxia, catdiac lamponade' tension
pneumothorax, and air embolism, each evolving at a different pace Gei
the picture?
Where to cut?
Choosing the corfecl incision may well be your most important strategrc
decision jn a trauma ihofacoiomy. The wrong incision can turn a
siraightfoMard case into a technical nightmare'
TOP KNIFE The Arl & Crofi of Trourno Surgery
For the hemodynamicaly unstable patieni in need of a crash operation,the utility incision is af arterolaterai thoracoiomy through the 4thrntercostal space on the njured side. Ths quick incision keeps youroplions open. You can easily exlend it across the sternum to the other sideof the chest or go into lhe abdomen wiihout having to reposition thepatient. However, flexib lity comes at a prce. Whle an anierolaterathoracotomy allows you to get to all parts oJ the lpsilateral ung, trying toreach a deep posteror chest wall bleeder or a posterior mediastinalstructure may be virlually impossible.
For a penelrating wound to the rlghi lower chest with hemothorax,consider going into ihe abdomen frst . The l iver dom naies ihe rghtthoracoabom nal reg on and is, therefore, the most ikely source o{ severehemorrhage (Chapier 10).
Begin with anterolateral thoracotomy in the unstable patient
[,/ed an sternoiomy is a good ncision for precordia] siab wounds, s nceit gives yo! flll access to ihe heart and great vessels of the uppermediasiirum. lts biggest advantage is extensibilrty; you can easily carry itinto the abdomen, neck, or along ihe clavicle. lt also provides access toihe hilum of each lung, but access to the per phery of the lung is resiricted,and the oosterior mediastinum is naccessible.
In lhe patient aciively bleeding from penetratlng trauma to the thoracrcoutlei, you can stumble nto a big lrap if yo! choose lhe wrong incision.You rnust base your decision on an educated guess as to the source ofhemorrhage. lf the patient presents in shock with a arge hemothorax, youtypically begin with the ltility anierolatera ihoracotomy but nray discoveryou cannot repar the injury through this incision. You must thetr rapdlyextend t (or make a new one) to gel to the bleeder
lf the patieni is not aclively bleeding into ihe pleural space, mediansternoiomy is a good incislon for right-sided and midline thoracjc ouiletwounds, giving you access io the rnnominaie artery and rts brarches,However, it is difficull to get to ihe leit subcavan artery from the fronlbecause the vessel is intrapleural and posterior So, in a patient with a
ll The No-nonsense Troumo Thorocorornv
penetraling injurY above ot
below the lett clavicle, gain
proximal control of thesubclavian adery ihrough a
high left anterolateraLthoracoiomy in ihe 3rdintercosial space (above
lhe nipple), recognizingthat you cannot f ix the
vessel through this very
llmited incision. You will
have to expose the lniuredsubclavian artery through a
separaie incision (ChaPtef1 3 ) .
The classic tfap door incision is a creative comblnation o{ a medran
sternotomy, left anterolatera ihoracotomy, and a lefl clavicuLar incision lt
requires forceful retraction to open the upper mediastinum and has a high
incldence of postoperative causalgialike pain due to siretching of ihe
brdLhal p 'e*us ard olher le 'ves We rpver uqe i l because you ca1
achieve the same exposure using jLlsitwo o{the ihree elements of the trap
door with much Less morbidity
Slable pat.€,lls hrde iewer surorises You ̂ 'row your sJ-gica iargel
iiom preopefative imaging, and this targei dictates your choice of incision
Extensibi l i ty into another visceraL compariment is usual ly not a
consrde-aton. Posleror medlasl i , ral s lruclLrF: sucn as lhe ao' la or
esophagus are approached through a posierolateral thoracotomy at a level
corresponding to the injury ln fact, poslerolatera lhoracolomy provrdes
such outstanJing exposure of the chesi wall, lung, and mediastinum that
one o{ us occasionaLly uses it in actively bleeding paiients, especially if the
peneiraling wound is posterior and low.
Caretully select your incision for thoracic outlet iniury
TOP KNIFE The Arl & Croft of lroumo Surgery
Anterolateral thoracotomy made easy
Place the patient supine with bolh arms exiended, and shove a roLledsheet behind the scapula 1o siighily Jift and medially rotate the operatedside of ihe chest. A double- umen endolracheal tube rapidly placed by acompetent anesthesiologisl gives you a huge technical advantage.Working around a collapsed lung is a walk in the park compared with theiorture of trying to squeeze your way around a rhyihmically inJlating
Make a bold cui inthe 4th lntercosialspace, In a maepaiient, this s belowihe nipple. In afemale, retract thebreasi cranially andmake the incision inthe inframammaryJold. Avoid the bukof the pecloralismajor by placing theincision immediatelybelow it.
Think of this operaiior as ihe thoracic equjvaleni of a crash aparotomy.Work quickly and deliberaiely. This is not the time to be minimally invasivoor go hunting for stray erythroc).tes with your thunder stick. lust grab akn fe and go into the chest. Carry your incision from lhe sterna border tothe midaxillary line, foLlowng the intercostal space in a sLight upwardcurve. Laterally, you soon encounter the law of dim nishing returns: thefurlher you extend your inc sion, ihe rrlore muscle you have to cut w th less
An experienced surgeon eniers the chest with three bold strokes of theknife: the Jirs l div ides lhe skin and subcutaneous tssue; the second cutsthrough the pectoralis fascia, the pectoralis muscle anteriorly and theserratus laterally; ihe thifd is a short incision in the intefcostal muscles thatbrrngs you into the pleural space.
Grab a knife and dive into the chest
rr The No-nonsense TraLrmo rhorocotomv g
ib spreader carefully to create your work
lf necessary, extend Yourincision to the other side ofthe
chest by cutting across lhe
sternum cleanly using a Gigli
saw, an oscillating saw, or
bone cutters, When crossing
the stemum from left to right,carry the incision uPwafd to
lhe 3rd intercosial sPace to
stay above the right niPPle,
thus iacilitaling exPosure ol the
upper mediastinal structurcs,
especially the innominaiebifurcation.
anterolaiefal thofacotomy s failure to identify and
ends of ihe internal mammary arlery When the
and vasoconstricied, this deceitful artery seldom
Once you have cfeated a
window inio the P!eufalspace, feelfor any adheslons
beiween ihe lung and the
chest waLl. lf the way rs clear,
take a pair of heavy MaYo
scissors and boldly cut lhelntercostal muscLes alongyour line of incision lnsert a
rib spreader inio the incision
wiih the handle ioward the
axilla; oiherwise, the handle
wi lL be in your way when Youtry lo extend the incison
across ihe sternum, open lhe
The classic pidall in
ligate the transeciedpatieni ls hypotensive
TOP KNIFE The Art & Croft of Troumo Surgery
bleeds. After you close the chest, it soon makes its presence known. lfyoudon t tie the ilansected ends, you guarantee your patient an early return tothe OR.
Don't forget the internal mammary artery because it won't forget you
Once inside the chest
ln most trauma thoracotorfies you will not have the befefrt of a double-l!men iube, and the anesihesiologist will not be able to drop the lung uponrequest. With the lung inflated, you in tialy see ltUe except a rh,,thmtca ybulging balloon and blood arolnd ii. To explore ihe chest, you mustmobi l ize the lung.
The key maneuver iscutting the inferior pulm-onary ligamelrt. Gentlyplace your non-dominanthand below the lowerlobe of the lung, pul l i tcranial ly to put the nJeriorp! monary r gament ontension, and divide i t withscissors, Remember thatihe ligameni ends at thein{erior pulmonaryvein, anda lacerated pulr.onary veinmay bring your operaiion io a speciacular premature end. Now, you canretraci the ung and wofk around i i .
Mobilize the Iung by cutting the inferior pulmonary ligament
Evacuate the blood, ask the aneslhesiologist to stop inflating ihe l!ngfor a rnoment, and rapidly assess the situation. Where is the bleedrngcoming from? Lufg or chest wall? Do you suspeci a perlcardial
ll The No-nonsense Troumo rho'ocotomv g
umoonade? ls there a mediastinal hematorna? Brighi fed blood pooling in
iie'chesi is frequenily from chest wall bleeders, whereas a mixture of
blood and bubbles usually comes from lhe lung Gushes of dark blood are
the hallmark of a pulmonary hilar iniury' Mediastinal hematoma indicates
potenl.al |a 9e vesse'rr iury. A burqing telsP pe icaroiJm is a lamponade
r.rntil proven otherwise. Oblain iemporary control oJ bleeding by pack ng
the chesi wall, manually comPressing the pulnronary hilum of a massvely
bleeding lung, or opening lhe pericardium to release a tamponade' Once
vou have temporary conlrol of hemoffhage' decide whether you are
lealing wiih BIG TROUBLE or a small problem (Chapier 2)
Are you worried aboui the other side of ihe chest? You certainly should
be because you cannot see ii Any doubts aboul bleeding ln the olher
pleural space (eg suspicious trajectory or unexplained hypotension)
should prompi you to push your hand immediately anterior to the
poricardium lo creale a window inio the olher hemithorax ls blood pounng
out of your window? Can you scoop up blood and clots when you push
your hand into ihe lateral recesses of the pLeural space? lf so' you riust
explore ihe olher srde
Nexi, opiimize your work space ls your incision adequate or do you
need beiier exposure? Using bone cutiers, you can divide the costal
cartilage o{ ihe 4th rib at the upper edge of your incision to allow the tib
spreader to open wider' l{ time is criiical, open ihe ib spfeader as much
as you have io, even if you feel a rib cracking This ls not an eective
iho;acolomy, and you must have adequaie exposure, whatever it takes li
all thjs is siiil not enaugh, the ace up your sleeve is, ol course' a clam_shell
e,(renq'or ac'oss the slFrnurn Ihdr wlll exoose evFrylh'ng lt rs l_oweve- dn
incislon ihai carries significant rnorbidiiy
You may wish to do something aboui the lung ihat is rhythmically
billowing i; your face You can ask ihe anesthesiologisi to reduce ihe tida
volume io enable you to work around the lung, or you can help push the
endoiracheal iube into tha contralateral bronchus This 'mainstemnring' is
mrcl_ easer on the nglt atnough lhe dgl^I Lpoer looe may'emain'o '_
ventilated. On the left slde, i is difficuli to blindly push the tube lnto ihe
n'ainstem bronchus Ercnangilg ar endo tt achear llbe {or a ooLble_lu-en
TOP KNIfE The Arl & Croft of Troumo Surgery
tube n m d'operation is difiicult and dangerous. Consider it wiih muchapprehension and only if nothing else works.
Optimize your work space and drop the lung il you can
Opening the pericardium
A classic errof of inexperience is leaving the pericardium unopenedbecalse ii looks okay from the outside. Wth ihe pericardium, what yousee is noi what you get, and a normal appearirig sac can easily hide aiamponade. Dlring a lefi anierolateral thoracotomy, retraci ihe left llng
posteriorly io expose thelelt laiefal aspect of thepericardium. Pinch it withyour lingerc to tent il upand make a nick wi ihscrssors anienof to thephrenic nerve. lf you seeblood drainlng through ihehole, widely open ihepe,cardium by sl id ing thes ighi ly open scissorsparal lel io the phren cnerve, and deLiver the heartinto the open chesl.
lf you fnd blood in the pericardial sac during a right antefolateralthoracotomy, immediately exiend inlo a clam-shell incision. You cannotproperly examine or flx the injured hearl from the righi side.
The closed pericardium is an enigma - open it!
1r T. e No no e-.F i 'oJ1 o -ho,o.otol v El
Conholling the PulmonarY hilum
Massive bleeding from a central lung injury requires swift control of the
hifu..-ftiht. "t"tping
is a 'doomsday weapon' because it is poorly
tor"rut"a fy "
put,.niin "hock
l{ you can stoP the bleeding by any other
a""n", "u"f'
^" a"*"f pressure, hemostatic sutufe' or rapid reseciion of
ihe injured segment - dont clamp the hilum
You can't even begin
to encircle lhe hi lumunless the lung is
mobi l ized bY cutt inglhe inferior pulmonarY
ligamenl. Ask ihe anes-ihesiologisi io stoPvent i lat ing the lungsmomentarily, and gaiher
the part ial lY- inf latedlung in ) /our non_
domlnant hand l ike a
bouquet o{ f lowersNegotiate a Satinskyclai,p arouno tne eni're hi'um laking cate 1o avoid Inrury to tne pn'eri!
""."J, *li"f' :s ararmilgly c,os6 Pulmora'v hilar Lla-1Ping requrres bolh
luna"; on. f'"na loldsl'ne open clamp while the other guides the jaws
around the hilum.
Clamping the hi lum
within the festricted work
space provided bY an
anterolaleral ihof acotomY
can be tricky because Youoften cannoi see whai J/otlare doing. There is a
sinrpler way to do it You
can tlvist ihe lung around
the hilum - ihe Pulmonaryhilar twist. Insiead ol
trying lo negotiate an
TOP KNIfE The Ad a Crofi ol Troumo Surgery
open c amp around the hilum, simply grab the mobiljzed lung with bothhands, holding ihe apex of the upper lobe and bas6 of the ower. Now,twrst the lung 180' so that the apex of ihe upper lobe abuts ihe diaphragmand lhe base of the lung is now where the apex fesrded until a fewseconds ago. Bleeding siops inrmediately. You may need to place alaparotomy pad in the uppor pleural space io keep the lung in ihe ups de-down poslton. This quck and simple maneuver is part icularly useluduring ER thoracotomy, where exposure and workng condii ions areseverelV comprorlrised,
Twist the lung to rapidly control the hilum without a clamp
Aortic clamping
The descending thoracic aorta s flaccid and pulseless, easiy mistakenlor an adjacent llaccid pulseess tube, the esophagus. Clamping lheesophagus does not improve the palient s hemodynamics one bit.
Placing a camp on the descend ng thoracc aorta during an urgentanterolateral thoracotomy is guided mostly by palpation rather than directvision. Relract the left lung anteriory and s ide your hand on ihe posterorchest wa lfrom lateral to medial, fee|ng the concavty of the posteror ribsas they arch toward the sp ne. The first tubular siructure you feel aga nstthe i p of your fingers is the aorta. You can eiiher manually compress iiagarnst the spine or place an aortic clamp across it freeing your hand for
The key to succ-essfu clamping is ioopen ihe panetalpleura. lf the media-stinalpeura overlyrngthe aoria remarnsIntact, your clamp willslide off and wiihoutobtaining a purchas,"
I I The No nonsense TraLrm. Tltt'.]t"t.trtv gI
Make a hole in the parietal pleura on both sides of the aoda' ellher w th
vour I nop. o ' N4dvo ccis\ors. A ' yo- 'eFo is a r im reo ooe r i ' rg usr eloLgh
io.c.o'mmooaLe, cta-p o'r eac'r q de o' tnF lrac' d tJbe MoreF^lersi{"
dlsseclion may avulse an intercosia vesselor irjure ihe aorta itse f' making
maiiers much worse
The "turbo" version
The turbo version of a thoracotomy for iraur'a is ihe much adveltised ER
(or resuscitative) thoracotomy, a heroic operailon tvp cally begun in the
shock room but, l{ successfu, aways concuded in the OR' To b-'gin a
resuscitailve thoracotomy, a you need is an endoiracheal tlbe in place' a
steady hand, a decent kn fe, and a brarn In geaf
TLlh "ooucl Ihe pdl ie_- ' " t l ar- o gel t o ' r l o i yoJ- $av na'e
,o-eor. rqu ' t od ne on ro lF L ' , les- a_d -_'r ' cui l i_g W're Jei-yis
not a central issue her€, your safeiy is Sharp instr!ments and needles are
promlnenily in play during resusciiative thoracotonry A cardrna ruLe'
iheretore, is to have onlv one par o{ hands in ihe operauve f ield yours'
AccideniaL siicks and cuis are a clear and Presenl danger In lhe organrzed
chaos ol a resuscltalive ihoracotomy, and paiients w th penetrat ng trauma
often carry transmisslble diseases Don t klll yourself or injure a co league
whiLe trying to save Your Patleni
Resuscitaiive ihoracoiomy is a classic damage coniroL procedure Atter
you open ihe chesi, only f ive maneuvers are done in the ER
The Five lMoves of ER Thoracotomy
lncise the inferior pulmonary ligament to mobilize the lung
Open the pericardium and slaple (or sutufe) a cardiac laceraiion
Perform open cardlac massage
Clarnp the pulmonary hilum or twist a massively bleeding lung
Clamp the thoraclc aofia
You can't clamp the aorta over intact parietal pleufa
TOP KNIFE The Art E Crofl of TroL,rno Surgery
lf the palieni survives, do everyihing else in the OR. lf oroanizedFleci l icar activiy does not retLrn w hin a reasoraole oeiod; i ime.recognize failure and stop. Don t endanger your team in futile situations.Regardless of your s!rgical talents and experience, you wlll not have manysurvivors of resuscitative thoracoiomy.
Worry about personal and t€am safety in a resuscitative thoracotomy
Median stelnotomy
Make a vertical rncision if thesternal r.idllne exiending from2cm above the siernal noich to3-4cm below the xiphold.Deepen your. incisio. io theanterior iable of ihe slernum,keepir ,g to the midl ine. Def inethe superior border of ihemanubrium and blunl ly developthe retrosternal plane from abovewith your finger. Then, go to ihenfer iof part of your i rc is ion andopen the I nea alba lmmediate ycaudal to the xiphold io bluntlydevelop ihe same plane from
Ask the anesthesiologist io stopventilating momentarily, divde thesiernunr in the midl ine using avertical sternal saw. Hook the toeof the saw beneath ihe siernumand pullon ii io elevate the bone asit is be ng cui to reduce the risk ofiatrogen c injury to substernalsiructures. Use the cautery tocon?ol oozing from ihe cut edgesof the bone. lnseri a sternal
r The No-nonsense Trouma Thorocoiomv El
retractof and graduallY oPen
it wiihoui cracking the
What You are looking lor rs
ihe left innorninate veln, lne
gatekeeper oJ the ihoracic
ouilei. Exiending across the
anterior aspect ol the upPer
mediasiinum, it is lhe lrrsl
structure You have to deal
wiih when dissecting rn the
thoracic outlei ln the trauma
sltuat ion, ident i fy, c lamP,
divide, and ligate the vein
. |"ft in-.in"t" u"in is the gatekeeper of the upper mediastinum
Closing the chest
Much like lrauma laparotomy, you have to choose beiween de{initive
"nJ t".por"ry
"to"r," o{ the chest ln eilhef case' place chest lubes In
r"^ "nerated
oleurar space or ir tne medrastinum ano irspecl lhe cl_est
wa', carefrrly io' nrercostal mJscLlar' and rlernal Tammarv bl'eoFrs
When should you consider temporary closure? lt is a valid optlon when
,"" ; ; ; "1"; ;n" '" t ' the patenl s raoidrv oete' iorat 'ns ohvsio'ogv or
i^,i- *, ",!"a
a rerurn to thp cl'esl to re'novF pacrs or pe'{o-m
".*,t',1" r""^'*. Tempora'y closure or 'ne cnesl means app-oxlmat ng
"" i" t t "
" |< '" to achieve ai- i rgnt cosure 'eav ng t ,re ' ibs dnd Lhesl wal
.rl"i"" ,""oor*^""a You" can rapidly close the skin edges with eiiher
" """ti**" fl"*y .*o{ilament suiure or a series o{ towel clips Rarely'
wien the heart is swollen and edematous and will noi allow even skrn
"ll",rr" ot
" ."di"n
"te'notomy nclsion' we iempotarily suture an emPty
r i""""""" r i r ia bag lo the ;k in edges,whi le the underly ing sternum
,"."in" oo"n This L ihe thoracic equivaleni of the plastic bag closure
described in Chapter 4
E ro, *",rr,n" on & crqft of Troumo su,sery
Skin-only closure of an anterolaieral ihoracotomy has one bigdrawbacl: i, brFeds Wh,Je rraking rhe ;rcrs,on, you ryprcalry ojvrde asLDslart tat mass of chest wah muscles in rhe rateralpa.r ol tne rncisror. l fyou don't approximate this m!scle mass, you will have coniinuous oozino
111-l"l ]'Tq" inio significani ongoing btood toss, especia y ii thlparent rs coagutopathic.
. Formal closure of an anteroJateral ihoracotomy is straighifoMard.
1ll.:: T,":: tl" '* usins rs6yy e"r,"o","| su,u.es tor,owed oy rayeredcrosLre ot the chesr wdl l rLscres, lascta and skin, h c,osing a c,am-s\el ,
li"llir'J;1,,5i?il" *'e to preciserv reapproximate the djvided sternum
T H E K E Y P O I N T S
) Begin with a/.rierolaterat ihoracotomy in the unstabte patient.
) Carefully setect your incision for thoracrc ouuet injury.
) Grab a knife and dive inio the chest.
) Don't fofget the jnternal mammary artery because it won,t forget you.
) Mobilize ihe lung by cutting rhe inferior putmonary tigamenr.
) Optimize your work space and drop the Jung ri you can.
) The closed pericardium is an enigma - open rl
) Twist the lung to rapidly control the hllum wthout a ctamp.
> You can't clamp the aorta over intact panetat pleura.
) Worry about personal and team safety in a reslscilatrve thoracotomy.
) The lefi jnnominate vein js the gatekeeper of the upper mediastinum.
Chapter L2
The Chest: Inside and Out
Good iudgmelll cofies t'rcm e'perteflce'
i, prri ir"i, o t "
f 'o ttl Poor i u dgne n I'
- Arthur C. Beall Jr', MD
You are inside the righi chest doing a thoracoiomy for a gunshol injury
'" ;: il;';;;;;";t You a'e rerreved ro see the rLns is .,'oi br'edi's'
il,.it '"iit* '" -' rs lrom tne bullel l-olc in tl^e chesl wal" P'obabrv
i"i ". ",","""t" """,y. ll roo(s ke a,si.nple p,'""".r""1j::i,"""j#"ri;^:hemostanc sttch Then' as you ky to gel to rr
1"."""J" 1""""""" oehi;d the diaphragm' it gradually dawns on you '
ihings are far ffom simPle
Wiih the lung rh}thmically billowing in your {ace' you can barely see ihe
or""l". iu"" ,itou ao' getting lo it through an anterolatefal thoracolomy
ni",ni ""."tri'* i.pos-srure Wnen vou rinattvfl""t?iJilJ
['il1i:a frgure of I stltch, you discover you cann(
n"""d'" b"""r"" yo, k""o bu-p:ng rrlo 'bs lhe ilrercoslal -pace rs lu5r
;;;l; ";;;"'; """"m'odate
a rul' swins ol Ir'e reedle Welcome to
the big leaguesl
You have just come across a notoriously underrated iniury _ one ot the
"lial"n .on"t"r"" of traurna surgery lt is certainly not the only one
;;ffi il";;, " i*i "f :*ti";";1"*:"ry"13i$,:1,",,i,:lfilf;(Chapter 5), a bleeding hole in ihe psoas n
i;;; i" ;i" rower extremitv ":::"]:.:"1'1" 1""il:"".i:i::l"j ;;#:1good "xd-pl€s TheJ a'e not"t o'_T1:'."-1ldo.*,d ar ri,sr grarue. Bur
to lhe surqical soul and may seem slralgl
*nl" r", iru. *". - yo'r discover you-a'e in deeper waters than you
thouq,1t, somotime. wel, over yoJ'heao The l^idder mo'1slert o{ Lrauma
,uil"orl oo",a,t" "'"",iv;ty
ano imag;narol {orcing yotr lo Lome up w ln
unorthodox solutions
TOP KNIFE The Art & Croft of Trourro Surgery
Bleeding from the chest wall
, The intercostal and internal maramary arteries bleed furiously because
lhey have a bidirectional blood supply. To achieve etfeclive hemosiasis.yoL mJsl conlror tne artery t-om botn s,des. The cnalrenging chesi watio'eeoer,'s not tl.e one localed -maoiatelv benFath your ;clio^ s.a,,.gyou n lne'ace wher you open the chest. h is the cunlrrg. Lnreachab,eInjury, very high or very /ow on the cheet wall _ a bJeeder you can bareJv
Your frrst priorrty is temporary control. Raproty assess the situation: caryou see the spurting vessel? Are you dealing with a discrete arterv (rnpererrating trauma) or wrt" d,f,use oozrlg f.om extensrve traLma to ciestwall muscles (in blunt trauma)? Are the adjacent ribs fractured? ls iheremore lra'r one sou.ca or b eedirg? Depeloing o.r yor,r, indr1g.. co_p.esstne oreeder w.tl your .inger, clanp ii, or tempora.'ty pack ir.
Next, opt imize yourexposure. lf the bleeder isvery low or very high on the .---chest wall, you may have iomaKe a new tower (orhigher) incision to get io it.A n€at trick is to move twointercostal spaces up ordown through the same skinincision and re-enter ihechesi through a moreappropnate rmercosla space,g ving yourself a better shoiat conirolling the injury. Insome cases you may need a
Now, choose an appropriate hemostatic technrque. lf the bleedinovessel is r ighrin front of yoL. s,r1py ctamp a,ro sr,rure-. igate rt. Th:si,usually possible with the internal mammary artery because ii runsperpendicular to ihe ribs and is relatively easy to reach in its anteriorlocatron. A transected intercostal artery js more chailengjng. lt often
l2 The Chesi: Inside ond Ouf
iniercosta rnusces and requ res aretracls in belween the surroundingblind hemoslatic figure of I suture.
The secrel of successis noi only choosing ihecorrecl needle stze, butalso orienting the needlepaih to be paralle - notperpendicular to theadiacent ribs. There is noienough space betweenthe ribs to accommodatea fu I perpendicular swirgof a large neede, sounless you drive theneed e parallel to the ribsyou won t be able iocomplete ihe arc andextract it.
What should you do if the henrostatc siitch doesn t work? Hefe, a littletactical creativity can go a lorrg way. Consider using hemostatic metalc ips. Alternaiively, if the mnedlaiely adjaceni rib is shattered irio severalfragments, rapidly resectlng a fragment adjacent to the bleeding vessecan give you valuable space for r.aneuvering.
lf all else lails, take aheavy monof ameni sutlreon a large needle andencircle the ent ire r ibinrmediaiely cephalad to thebleeding ntercostal vessel,igaling the neurovascularbundle en masse andcompressing it against therib. Do it both proximal anddislal to the bleedlng siie.Postoperalive intercosialnelralgia is an acceptableprlce for this l i fesaving
)"'
TOP KNIFE The Ad & Crafi of Troumo Surgery
Another last resort technique thal works with large bleeding craterstrom high caliber glnshots rs baloon tamponade. Insert a arqe Folevbal lool carheter lhrougr ihe niss, 'e racr f .or oJlside i r-o the ch"sL,nflate the balloon, and pull hard to tamponade the bteeding. Ctamp iheFoley flush with the chest wall to maintain iraction on ihe catheier, andsuture the clamp to the skin to preveni accidental dislodgment. Leave th scompressing balloon in place for a few days to ensure thrombosis of theiniured artery. We have also stuffed bleeding bullet tracts in the deepposterior chest wallwith local hemostatic agents or bone wax, much likewe do wi ih the hosing ver iebralar iery in the neck (Chapter j4).
A most ffustrating situaiion is diffuse multifocal oozrng fronr extensivedamage to the chest wall, wiih mu t ple assoc ated rib fractures. D recihemostasis doesn't work, and you rapidly reallze your ony opton is ioconirol obvious arterial bleeders, pack the damaged chesi wall, andrapidly bdi lout. T-F"e are oftan lerhal in iLr ies.
Suture intercostal bleeders parallel to the nos
The injured lung
Despite obvious anatomical differences, the bleeding lung s striknglysimilar to the injured llver In both organs, you deal with peripheral iniurlesusing a variety of hemostatic iechniques, while ceniral injuries {close to thehilum) are very bad news. In both lung and llver, surgeons use hitar controland non'anaiomical segmental reseciion but are wary of Jormal extensiveresection (lobecionry n the /iver, pneumonectomy in the lung). Theconcept ol tractotomy, a most usef!l iechnique for ihrough-and{hroughlung injuries, was originally borrowed from hepatic trauma.
Yo! can suture superficial pulmonary lacerations, but your mosteffeciive weapon in dealing with the bleeding lung is sfapled nan-anatomicresecllon. How s il done?
Define the preciselocat on of the injury anduse a l inear cutt ingstapler to rapidiy openthe intef lobar f iss!re, i ffused. Now, take a goodlook at the injured lungsegment and plan yourline of reseclion. Your aimis to remove ihe injuredtrssue with the eastamount ot surroundingheaithyparenchynra. Havea I stap ers and 3:0 or 4:Opoprypropyrene sutures
rZ rne Chesi: rnslde onct Out @
Pulmonary tractotomyrs a an elegani lung-sparing solutton fort h r o u g h - a n d ' i h r o u g hpenetrating injuries ihatare too deep for aslapled reseci ion. Theunderlying principle is tolay open the tract so youcan gei to the bleedersinside it. In oiher words,you connect ihe iract tothe lung surface bydividing the br dge ofnssue between them.
readily avaibble before you start. Ask the anesthesiologist to momentarilydeflate the injured lung. Use eiiher a wide inear siapler (60 or gomm) orseveral applications of a linear cuttng siapler to resect the injuredparerchyma. lf lhe stapled line of reseciion continues io ooze or leak atr.underrun it wilh a cont nuous monofilarnent sut!re.
TOP KNIFE The Art a Croft ofTroumo Surqery
Inserl one arm of a l/nearcutiing stapler (we prefer iouse a vascular staple load)into lhe missile tract andapply the oiher arm to yo!rchosen target sudace,C ose ihe siapler and lire it,layifg the m/ssile iract wideopen. Now, carefuly jnspect
I for beeding vesse]s andsuiure-ligate ihem selective yusing 4t0 polypropyene. Donot close the traci,
lf yo! don i have a lineaf cuiting siapler, you can do the sanre tractotomybetween two iong aortic clamps appjied to the bridge of trssue overlying ihemissiletract. After selectively co.trolling bleeders in the open iraci, underruneach aoriic clamp wiih a 4:0 polypropylene surure before removing ii.
Pu monary lractoiomy works so well ihat you should consider using iteven in deep penetrating wounds that are not through-andthrough (i.e. noexit wound). Inseri a fnger inio ihe mssi le tract and assess how mlchuninjured lung parenchyma mlst be crossed to complete a thro!gh-and-ihrough tracl. lf ihe dislance is short, use the stapler as a ,missile, tocomplete the lraci, push ng ii through the tract uriil the iip emerges fromthe other side of the lLrng. Part oi the tract will be iatrogenic, but a ?aci isa tfaci, and therefore amenable to tractotomy. Lay it open and suture-ligateindividual bleeders.
Pulmonary hactotomy is a neat solution to a ditficult problem
BIG TROUBLE with the lung
Central lung injuries are deadly because they are difficult to controJ andrepair They are classrc examples of Blc TROUBLE (Chapter 2), whereorgafzing your altack and your team before jumping in can make anenormous difference.
l2 The Chesl: nslde ond Out
When confrontedwith massive bleedingfrom an lnjury close tothe pulmonary hi lunr,rapidly mobi l lze ihelung, gathering it in yournon-dominaft hand,and pinch the bleedinghllum beiween thumband foref inger Thesimiadiy to ihe Pringlemaneuver rs oovous.Now organize youfanacK: rmprove expos!re, "mainslera ' iheendotracheal tube i.to the conlralatefal bronchus if possible, and get a fullsei of vasc!lar instfuments and an autotranstusion device.
At th s point, your oplions depend primarily on the mechanism of nlury.With a simple stab wound, pinching the i f j l red hium may give yoLr jLtstenough control and visibility to rapidly do a aieral repalr using 5:Opolypropylene. The situation bears an uncanny resemblance io the injuredportal ve n n the hepatoduodena ligament. In boih cases, you are dea ingwith a lacerated low-pressure (but h gh flow) sysiem wiih n a very narrowanatornic space ihat affords you litlle room for maneuvering or comfortableclamprng.
Control the pulmonary hilum between thumb and forefinger
A central glnshot injury is bad news. Dar.age is r.ore extensive, youoften must clamp ihe hilur., and may be forced to reseci a lobe (or eventhe entire lung) io achieve hemostasis. A theoretically appeallng opton fofhilar injuries is vascular control from within the pericardium becalse it isbased on the prlnciple of anaiom ca barf ers (C hapter 3) .
lf yo! open ihe pericardium anterior and pafallel io the phrenic nerue,you are work ng if uninjured v rgin terrilory, much ltke working above theinguinal lgamenl n a groin gunshot wound. However, this lakes t ime and
TOP KNIFE The A.t & Crcrii ol Troumo Surgery
requires thorough kfowledge oJ itrtrapericardiai a|atomy - nol a goodopiion for the gerieral ifauma surgeor facing a certral lung injury n arapidly exsanguinailng patient. In practice, a gunshot wound close to thepulmonary hiufir means a rapid lobector.y or, in extreme circurnstances,pneumonectomy,
A siapled pne!nrofectomy is a technically simple blt physlologicalydevastatrng operatrve maneuverr so use it as an absoluie Last resod,Exsanguinai ng traunra patients do not iolerate acute removal of the iufg.Pneumonectomy slops the bleed ng but often eads to acuie right heartfailure, henrodyfamic collapse, and very high mortality.
lf, despite all efforts, you have no choice but 10 take out the lung, bringa 90mm inear siapler w th a vascular staple load across the eni re hilum.The iechnical princ ple is to move the siapler as d sial as poss ble io giveyourseLf room for a suture llne should siapling requife reinforcement.Carefu ly close ihe stapler across the entire hilum, fire it, and remove theung. Take hold of boih edges of the stapled stump wiih Allis ciamps, andoniy then release the stapler There s always residual bleeding from thestapled line of reseciion. Control ii wiih a running monof lameni slture.
Do a stapled pneumonectomy only as a last reso{
The thoracic esophagus
Approach an injury to the upper and midthoracc esophagus through arrght posierolateral thoracotomy in the 4ih intercostal space. The injuredlower thoracic esophagus is accessed ihrough a left posiero aleralthoracoiomy in the 6-7th ntercostal space.
The bail out so ution for an esophagea perforation is proximal drainageto conved the fiee perforaton inio a controlled fistula. The cardina sin iscreating a dead-efd esophageal pouch above ihe injury, an ufdrained'pus sausage" that is a source ol ongoing sepsis and slowly kills thepaUent.
l2 The Chest: lnside and Oui
Drain the perforation byinsert ing a large-boresuclion drain through iheperforaiion and up into theproximal esophagus, andsecure it in place. lf youcan get an esophagea T,iube, use it. lf possible,approxrmate ihe edges ofthe hole around the dfain-A ways remember to drajnthe pleural space with aseparate drain or a tubethoracosiomy. Use thisdamage conirol opt ionwhen you have to bail ouiapproximated without iension,24 hours from injury) and theprimary closure unsafe,
in a hurry, the injury s too large to beor the operaiion is delayed (more than 12-pleurai space is severely inflamed, making
An esophageal perfofaiion is a hole ln the gut. lf you decide to close it,always begin by carefully debrjding and deflnlng the edges of the nrucosaldefect, just as you would do for any other part o{ the Gl tract. Do notmobi|ze lhe esophagus out oI its bed because you will devascularze it,jeopardizing your repair. Close the perforation in two layers (mucosa andmuscle), and drain the pleuralspace.
Coverihe repairwiih a vascularized pedicle of tissue. Depending on iheoperaiive circumstances, ihis can be an iniefcostal muscle flap, a Thalpatch of gasiric fundus (Chapter 5), or a chunk of omenium. Perlcardial orpleura flaps are not well-vascularrzed n ihe acute settinq, so don't usethem. Provide a roule for early enieral feeding
Drain an esophageal pe oration as a bail out solution
TOP XNIFE ]he Ad a Crofi of Troumo Surgery
The majol airways
The ciose anatomical proximlty of the major airways io the grealvessels, esophagus, and lungs vidual ly guaraniees you wi l l rarelyencounter an isolated injury to the intrathoracic trachea or a majorbronch!s. [,4ajor airway injury typically iakes second seat to hemorrhagebecause gushing blood takes prorily over leaklng air.
The damage conirol soluijon for an rntrathoracic tracheal irjury is ionegotiate the efdoaachealtube past the injury bypassing jt to prevent amassive air leak. For a rnainstem bronchus injury, ihe bail olt soluiion ismainsiemming ihe endotracheal iube into the contralateral bronchus(Chapter l1). Air Jeaks from smaller arrways can be managed initially witha chest tube, with delayed reseclion of the involved lobe.
lf, during thoracotomy for trauma, you ercounter a straighfiorwardlacefation of the trachea or a major bronchls, fix it with a sing e row ofinterfupied absofbable sutures. Do not use a non-absorbable sutufe in theairways; il leads to granu oma {ormaiion and tater stenosis. Fof all otheriniurjes thai require complex reconstrlctions, the smartest thing you cando is resist the temptation io tackle them or your own, and get the help o{an experienced thoracic surgeon,
)
Fix skaightforward major airway iniuries with absorbable suture
T H E K E Y P O I N T S
Suture inlercostal bleeders parallel io ihe ribs.
Pulmonary tfactotomy is a neat solltion to a difficult problem.
Conirol the pul. .onary hi lum beiween thumb and foref ingef.
Do a stapled pneumonectomy oniy as a last resort.
Drain an esophageal perforation as a bail out sotLrton.
Fix straightforward malor a rway injuries with absorbable suiure.
Chapter 13' I horactc V ascu lar I ra uma
for the Ceneral Surgeon
The rcad to the heart is orrlY 2-3cm in a dircct lifie, but
it has taket surgery flearl! 2400 ye.rrs to haoel it'
- H.M. Sherman
Injlries to ihe heari and ihoraclc great vessels have an idtating
tendency to force lhemselves on you. ll you ate a g€neral sutgeon' the
major vascular structures of ihe chest are not your nat!ral habitat, and you
wou d much raiher have a cardiothoracic colleague deal with ihem With
bluni aodic injuries ihis is noi only Posslble but ls also a good ldea
because you are dealing with a contained hematoma There is time to
delineate ihe njury by angiography, conslder various options (including
endovasculaf repair), or transfer the Paiient to another facility Not so with
penevating itauma, where the patieni is actively bleeding and often ln
shock. You musi take a deep breath _ and plunge in A phone call to a
cardiac surgeon is noi a valid resusciiative maneuver for cardiac
This chapier deals with lhoraclc cardiovascular trauma from the
perspective of the general surgeon Most penetratlng injuries io the heart
and thoracic great vessels can be fixed using straightforward vascular
principles and techniques. lf you gain rapid access to the injury and keep
your wlts about yo!, yoLl have a good chance of saving the patent
Accessing the bleeding heart
The operative encounter with a stabbed heari is often one ol the "osi
reward ng experences a surgical resident can have li involves a rapld
simple procedure that revives a patlent who, uniil a {ew minutes ear ier,
TOP KNIfE lhe Arl & Croit of lroumo SLJrgery
was virtually dead. Don'i let ths gfatifying experience mislead you.Cardiac inlufres can also be extremely vicious and leihal. They conre in iwoflavors: simple and complex.
A simple cardac injury is a small accessible laceration, rnosl often astab wound. Oulcome is deierm ned by how quickly you crack ihe chesiand release the tamponade. These patients don'i die ol exsanguination,and cardrac repair is usually easy.
Complex injur ies are mutiple, inaccessrble, large, or involve thecoronary arteries. Re ease of tamponade is only the firsi step in an uphilbattle. Conrplex cardiac wounds are Blc TROUBLE (Chapter 2), carryifgvery high morlaliy rates even rn the most experenced hands.
How do you get io the wounded heart? lJ yo! have akeady begun witha resuscilative lhoracotomy, open the pericard um longitudinally, anterorto ihe phrenic nerve. Release the tamponade and deliver the heart nto iheoperative fie d. Injuries io ihe righi side of the right ventricle or to the rightatrum cannoi be reached through a left anterolateral thoracotomy, soextend your rncison across the sternum.
lf the patieni is not ,in exfremls, consider do ng a median sternotomy.This incision takes a ittle more time, and your access to a postenorcardrac wound from the front is more difficult. We prefer a left anterolateralihoracotomy for most cardiac wo!nds, especially gunshot inj!ries thatoften involve damage to oiher ihoracic structures. We reserue mediansiefnotomy for precordial stab wounds in relative y stable patients.
Do a left anterolatefal thoracotomy for cardiac gunshot wounds
4 A,MI @-4 ".z"zc1 tW*V.-r"*
l
F 5f--',t ? +to
l3 Thorocic VascuorTrauma for ihe GenerolSurgeon
Temporary bleeding control '
Once rnside the pericardium, rapidly evacuate blood and clots, locatethe injury, and select an appropriate lemporary hemostatrc technique. Youlassistant's finger is an excellenl first choice, but there are other options.
During resuscjtative ihoracotomy in ihe shock room, temporarilystapling the laceration wiih a skin stapler s a cooltrick since a stapler isso much safer ihan a needle. Conirol a larger wound by inserting a Foleycatheter through the hole and inflating il. Use a Satinsky side-biiing clampto conlrola rohl atrial Laceration,
lf the damage is extensive or theinjury inaccessible, you may have toresort to temporary inflow occlusion.lf you clamp both the superior andinferior venae cavae, ihe heart willempty and siop, giving you a coupleof minutes (not morel) to suture thelaceration in a dry field. ll you are nota cardiac surgeon, the simplest wayio achieve inflow occlusion is byco..press ng lne \lg!]._jl]Illl!!-rmanually againstthe heart in a lateral-to-nredial direciion so the atrium
ToP KNTFE The Art & Croft of Traumo Surgery
cannot fill. Use inflow occlusiof only if you have no other chojce. lt is easyto siop the heart, but much more difficult to get it going again. In a cold,fibfillating heart, inflow occlusion will be a term nar evenr.
Inflow occlusion is your ultiftate weapon in cardiac trauma
Restarting the heart '
When the heart s not contracting effective y, begin open cardiaccompressions. lf operating through a median sternolomy, compress iheheart between bolh palms (wlihout thumbs). In a left anterolateralthoracotomy your wofk space ts imited, so compress with one handagainst the sternum. Restartthe heart us ng a combination of open cardiacmassage, cross-clamping of the descending thoracic aorta, eplnephrine(1mg) io achieve coarse ventricular fibrillation, and cardioversion usinginiernal paddles applied d rectly to the heart ai 1O-30 Joutes.
What should be your firsi priority if ihe bleeding heari is not coniractifgeffeclively? Should you fx the laceration first? Rapldly cosing a cardiaclaceration before it resumes danc ng rn front of you is certainly tempiing,but it may take iinie, and your repaif nray fa I apart when you compress theheart and iniect lnotropes. Epifephnne is the eremy of the myocardialsuture line because it induces forceJul coniraciions caus ng sutures to ripthrolgh the musc e. lf you fix the aceration and then restart the heart, youmay have to reinforce (or even redo) your suture line once ihe heart beginsbeating again.
Resiariirg ihe heart after repair may not be easy. A severely acidoticpal ient wl l benef i t f rom a bous of sodium bicarbonate pf ior todeflbrillation. Even nrore mportant is external irigation with warm saline torewarm ihe head irnmediaiely before applyjng ihe paddles. Use lnotropesonly if nothing else works.
Epinephrine is the enemy of the myocardial suture line
l3 Thorocjc Vosculor Troumo for ihe cenerol Surgeon
Repairing simple cardiac wounds
C ose a simple laceration
with a 4r0 qg&absorbablemonofilam6nt suture. Sew n9the contracUng myocardiumis more di f f icul t thanoptimisiic lluslraiions iike thislead you to believe. Noi onlyare you workng on a movrngtargei, you aso are dealingwith a muscle that tears quiteeas ly,
Some surgeons use Teflon pledgets to reinJorce the sulure ine. Werepa r a lacerated veniricleaviih interrupted simple sutures. Your bites iniothe heart muscle should be deep but not full-thickness. The diffcult part isnot placing the suiures, but tying them. Unless you take special care notto tighien the knols too much, you will end !p with a torf myocardium anda bigger hole ro fix.
ln an elderly patient or an edemaious or friable myocardium, usehorizontal mattress sutures wiih pledgets. Partial inflow occlusron bymanually compressing the right ak um lowers pressures in the v€ntricles,a useful adjunct when sewing a compfomised myocardium.
Since pressure in ihe righi atrium ls low, you often can control an atriallaceration temporar ly with a partially occluding Satinsky-type clamp andthen fix it with a running suture, as you wouLd a arge vein. Grazing non-penetraiing rnyocafdialwounds often b eed persistently and require suturerepaif just ike a lull-ihickness aceraiion.
Tying sutures is the challenge when sewing head wounds
E ,o, a",rr rnu on & croJr oi Troumo suraerv
Complex catdiac wounds
. When.you can,t fix the injufed heart wiih a few simple sijtches, you are
f T-n-". ?.,^1 "1n".,. :"d yoJr oarieni ras a nigh ,ihetihood or 1or na(.ngrr , une $uch eramplF is a poster io. card,ac wound. to get,o a postertoihole, you musi Jift ihe heart out of its bed, but the heart often protests bydevetoorrg ventncLla. arrhylhmia or arresring. In fact, trl ng lre reert up ,sanorher way oi achievirg in|ow occtusion, Be aware of th,s wnen yoJmanrpulate the heart, and lift ii gentiy and intermillently when addressing aposlerlor hote,
The technical solutionfor a /aceraiion ciose to acoronary artefy is a deephorizontal mattress suturethat dives beneath theaftery. Take special cafewhen tying this suiurebecause S-T segmentchanges or new O waveson the ECG monitor mayforce you to remove thestr tch and fedo i t . AnInlury to the coronaryartery itself is iypicalydistal sinc_" paiients withtransection of a proximalcoronary vessel are usuallydead on arr ival . Yourreal is i tc opt ion for acardiac laceration with a iransected distal coronary artery is to ligate thevessel and repair the hole, accepting ihe inevitabte ischemi; of thecorrespondrng myocardial seoment.
ir r+ *,:*! . '*-",rJ ',,, ^{\-i1 " L.^4
Cardiac tamponade caused by lnjury to the intrapericardial oreatvesse's is usJal lyreha,. On rhe ra.e occdsiol l ratyor, pnco.:rre, i . i r I hvepatient, success hinges on your ability to fapidly identify the inlury,
l3 Thorocic voscu ar Troumo for lhe GenerolSurgeon
temporadly conlrol il wiih your Jinger or a Saiinsky clamp' and fix ii with
simple latefal repair 'much easier said than done
In traurna atlases and iexlbooks you ofien see descriptions of heroic
repair techniques lor an injured coronary artery, patch repair of a large
myocardial defeci, or complex reconstructions ol the inirapericardial great
vesseLs. Althese may be possible in special c ircumstances when a
cardiolhoracic surgeon and a pump team happen io be readily available
However. for ihe routine trauma paiient arriving in the middle of the night
with a penetrating cardiac lnjury and operaied on by ihe traurna surgeon
on calL, lhey are science ficlion.
Use quick and simple solutions for complex cardiac injuries
The tholacic outlet
How to exvlore a meiliasfi al her atoma
Median sternotomy provdes
excellent access lo the superiormediastinum. A mediastinalhematoma looks Like a large
chunk of red jelly sitting aboveihe pericardium, oozing bloodand obscuring the anaiomy.This red jelly usually signifies amajor vascular injurY in iheihoracic oulei that You mlstfind and fix.
Exploring ihe suPeior media_
slinum is remarkably simllar to
expLoring ihe neck, as describedin the nert chapter. Both are essentially a lrip ihrough a minefield under
sniper flre. You must follow a trail of safely from one key anaiomlcaL
landmark to ihe next to guaraniee a safe dissection and siay oui oftrouble
TOP KNIfE The Ari & Croft of Troumo Surgery
Once ins de ihe chest, identifythe upper border of ihepericard um. lf the ihymus is inyour way, divide it betweenclamps and ligaie lt. You arelooking for the ielt innominatevein. lt is the gatekeeper of themediastinum, just as the facialvein is n the neck. Divding andligaiing the lefi ifnornnate veinopens !p the supe ormediasiinlmand gives you access 10 ihesupeior aspeci of the aortic archand rts branches.
Disseciion n a mediastinalhematoma is never easy. lfyou fee ost, a useful lrickis to open the pericardiumto or ient youfself . Thepedcard um is an anaiomicalbarr ier that blocks lheextension of lhe mediastinalhematoma, jusi l ike iheinguinal igament blocks theextension of a groin hem-atoma (Chapier 3). Byopening the per cardium,you can follow ihe aortcarch upward into ihehemaloma to identify ihevessels oJ ihe ihorac coutlet.
I 3 Thoroclc voscuor Trou mo for ihe Genero Surgeon
has ihe same consequences as il doesiatrogenic iniury
After ideniiiying and
dividing the left lnnominalevein, your next stop on the
mediastinal trail of safeiy isthe bifurcation of iheinnominale ariery, the media_st inal equivaleni ot thecarot id bi furcat ion In theneck. Your kay landmark isthe right vagus nerve as ltcrosses in front of theproximal r ight subclav anartery. Fallure io identi{Y lhevagus in ihe mediast inum
ln the neck - an inviiaiion for
Follow a trail ot safety in exploring an upper mediastinal hematoma
Youf nexi priority is proximal and distal control of the bleeding vessel
The vessels of ihe superiot mediastinum are niceLy arranged in two layers:
s!perficialveins and deep arteries Again' the simllarities to the neck are
strlklng. Control a venous injury with a side-biting clamp, and fix ihe hole
lf a simple lateral repair will noi do _ ligaie the veln without a second
thoughi.
When disseciing the proximal left carotid artery, you musi ideniify and
preserve lhe left vagus nerve as it descends between the caroiid and Left
subclavian artedes to cross in front of lhe aortic arch and give o{f the left
recurrent laryngeal nerve Proximal controJ of the lefi subclavian artery Ls
discussed laier in thrs chapter
Never just plunge inio a mediastinal hemaioma from blunt trauma The
most common blunt arterial injury in the upper mediastinum rs an
lnnominaie artery injury that presents as a coniained her'atoma (widened
superior mediastlnum) in a hemodynamcally stable patient Bllndly
entering lhe hemaloma is the worst possible error you can make lhe
inlurv js avulsion of lhe lake_off of the innominate artery Jrom lhe aortic
aich. In other words, you are dealing with a sde_hole in the aorta lt
TOP KNIFE The Art & Craft of Troumq Surgery
doesn'l take much surgical imagination io realize what wil/ hapoen if vouoelve nto -hrs rFnatonc u'rprepa.eo. lne correcl approac- is or;Jlvouilined in the next section of this chapter
How about distalcontrol of thoracic outletinjuries? As a general rule,the exposure provided bya median sternotomy isolten not suffic ent to a owdista conifolof the carotidand subclavian vessels. Amedran sternoior.y is,however, an eminenilyextensle incision, so yor,lcan easily cafiy it Into theneck or along the clavicle.lf you are going into thereck, drvide the strapmuscres oown |ow, fearthe r inseriion inio thesternum, to expose thecarotid sheath.
Never plunge blindly into the mediastinum in blunt trauma
Definitive repair and damage control options
In the upper mediastinum you almosi never dea/ wiih an isolatedpenetrating injury to a single vesse. There are always associated inlures,and clamping the rnnominate or caroiid artery carrles a subsianial risk o{stroke. So don't fiddle w th ihoracic outlei iniures; use the simplest afdquickest solution that will give an accepiable result. In most cases, thismeans a synthetic rnterposjtion grafi. We prefer knitted Dacron ratherthafePTFE because il is a softer graft with less needle-hole bteeding. The
1 3 i ' o o . ' , o , u o ' I o u - o o I ' G e _ _ ' o l 5 ' g e o n
normal arteries of the thoracic oullet afe extremely friable, and sewrng
ihem often feels ike sewing wet lissue paper
There are ony linriied damage control options in the thoracic ouilei
Ligaiion of the injured artery is certainly an option if you accepi ihe risk of
slroke. A temporary intraluminaL shuni is iheoreiically aPpealing and has
been used twice by one of oLlr colleagues but with no ong_lerm survivors
The only speclal vascular technique in the thofacic outlel is the 'bypass
and exclusion repair of blunl innominale ariery lnlury ll you aren t a
cardiothoraclc surgeon, you are unlikely to find yourself operating on this
injury, since the paiients are hemodynamlcally siable with a coniarned
hemaioma. You should, however, be familiar wiih the techn cal principle
The bypass and exclusion repair begins by exposing the ascendlng
aorta inside the pericardiunr and then obtaln ng disla! contro on ihe distal
innominate, right subclavian and right carotid arteries The s!rgeon
deliberalely avoids enteing the hemaioma around the ptoxlrnal innomlnaie
artery. A pariia ly occlud ng Saiinsky clamp placed on ihe ascending aoria
allows ihe surgeor to sew a 12nrm knitted Dacron graft end{o side io this
sde-clamped aortc segrient The innominate adety ls then dlvid€d just
proximal to its bifurcation, and the distal anastomosis (io ihe disia
innominate) is completed Onlyihen isasecond part ial ly occ uding camp
placed on the aorta around lhe take_off of the lnnominate artery The
hemaioma is entered, and the side hole in ihe excluded segmeni of aorlic
arch is closed with pledgeied sutures
[Jse Dscron fof thoracic outlet arterial reconstructions
The azygos vein
In penetrating chest traunra, azygos vern
wth lnjures to the adjacent centralalrways,vessels. The chalenge with an azygos vein
through a median sternolomy is extremely
injury is seen in conlunctronesophagus, or thoracLc out et
injury ls gelting io lt. Accessditficult, and it may even be
TOP KNIFE The Ari & Croft ol Troumo Surgery
difficult io reach lhrough a righi anterolateral thoracotomy, requiring anextension across the sternum. The irjury is tolgh 10 identify because whatyou Lrsualy see s just a hole in ihe right posterior mediastinum hosingvenous blood. Onc6 identified, clamp and suiure-ligaie the injufed veln,and meiiculously search for associated jnjufes io the adjacefi bronchusor esophagus,
The subclavian vessels
Before you embark on an adventure around ihe sLlbcavian vessels,palse to assess how necessary it really is. Are you operatjng for bleedingor ischemia? l f your circumslances are unJavorabie ( i .e. austereenvironment, lack of experience, other grave injuries), you nray well beab e to posipone the operation. If bleeding is from a missiie tract, inseri aFoley nto it and inflaie lhe balloon (Chapter 2). lf this stops the bleeding,an lmnrediate opefatlon may not be necessary. lf ihe arm is ischenric, asimple forearm fascioiomy can buy you valuable time. Endovascular stentsor stent-grafts are effective ali€rnatives to surgical repair of subclavaninjuri6s in non-bleeding patients.
lf you decide to proceed with an operation, proper positioning anddraping are crucial. Place a shouldef roll vertically along the thoracic sprneto drop the shoulders back. Suppod the head and roiate it to thecontralatera side to extend ihe neck. Prep and drape the patrenl's chesiwith the upper exiremiiy prepped free so it can initlally be fully adducied atthe patent's side and later abducted as necessary. You can get to thesubclavian vessels through either a supraclavicular incision or ihe bed ofthe clavicle. Your choce of incision depends on the opefai ivecircumstances and your experience.
lfyou are not sure whefe the njury is located along the subclav an arteryor if you don't have experience with subclavian exposure, the safest wayto obtain proxjmal controlis throLgh the chesl. Use a high (3rd irierspace)eft anterolaiefal th oracoiomy incision for injury to the left subclavian artery,or nredian sternoiomy if the injury is on the righi.
I3 Thorocic vascu orrro!mo for the Genero "'ntt"
E
When exploring a non-bleeding
subcJavian injury with mrnimalor no
hematoma around the clavicle, we
prcfer a supraclavicular incisionlvlake your incision a lingefbrcathabove and parallel to the clavicle,extending from the sternal notchlalerally to the distal third oi ihe
bone, a distance of approximaiely8-1ocm. Divide the Platysma andplace a self-retaining tetractor in
the wound, You must now go
through two layers of muscle.
Behind the divided slernocleidomastoid, idenlify ihe scalene fat pad and
caretully mobilize it from lateralio medjalln search ofthe phrenic nerve On
lhe left side, you should be able to identit ihe thoracic duct as ii enters the
iunclion of the left subclavian and iniernal jugular veins lf iniured' suture'
ligate it with a 6:0 polypropylene suture; il not' eave I abne
Th€ first layer conssisof the claviculaf head ofthe sternocleidomastordand the omohyoid laierally.Cut both muscles as closeto the clavicle as Possible,then reposition Yourretractor in a deeper Planeto op6n the wound. lf Yousee the internal juguLar
vein, deiine its latetalborder and reiract itmedially oul o{ harm swayNow you can access andisolaie the subclavian veln,bul the artery is hiding onelayer deeper down, behindihe anierior scalene
TOP KNIfE The Ari & Croft of Troumo Surgery
f , - \ 4 - ' Y L " J ' A
The key analomicaliandmark n exposing thesubclavian artery is thephrenic nerve behind lhe fatpad. During a subclavianexposure, i t is the ortslructure you must preserveat any cost, even f theanatomy is hostile. ltcrosses the anterior scalenemuscle from up and lateral1o down and medial. lsolatethe nerve on a vessel loopand gently reiract it out ofyour way, Now cui the anterior scalene mlscle as low down as you can,We dlvide the muscle piecemealwiih scrssors and noi diathermy becauseit does not bleed and is close to the brachia plexus.
Only a lhin periarter alascia rernains betweenyou and the subclavanadery Incise it to identrfythe periadveniitial planeof safeiy and encirce theartery. The thyrocerucaltrunk s com ng straight atyou and ls typically in yourway. Dividing and ligatingt helps you nrobilize ihesubclavian artery. Clearlyidentify the vertebral andIntemal mammary arteaescomirg offthe firsi part ofihe vessel to preventaccidentalrnjury.
The phrenic nerve is your key to the g.tbclavian a*ery
! 3 - h o r o - ' . v o . ! o , ' r o 1 o o _ e C a n ' o 5 r o e o '
As always, things become considerably livelier when lhe subclavian
adery is bleeding An expanding hemaioma fiLls the clavicular fossa'
making it difiicult to even palpate the clavicle When operatlng under such
adverse circumsiances, we prefer to go throlgh the bed of ihe clavlce
because i s a quiuker a1d simplef toLle'/h.t",'\ 4rd'1 +^ PL- 'lA
Make your incision dLrectly on the clavlcle io expose the medial hvo_
thirds ofthe bone. Score a line on the anterior surlace ofihe bone wiih ihe
dialhermy. Now use a periosteal elevator lo peeL ihe periosteum otf the
clavicle in a circum{erential fashion Divide lhe clavicle as far laterally as
you can wiih bone cuiters or a saw, then grasp ihe medial ffagment with
a towel cLip, and yank ii oul of iis bed Using ihe diathermy, take the head
of ihe clavicle off the siernum. Cutting the subcavius muscle immediately
deep to the clavic e bf ngs you face-toJace wiih the pfe_scalene lat pad
and the phrenic nerve, and you know your way io ihe artery from ihere
Distal controL ol the subclavian artery may require clamping the proximal
axillary artery. lf the clavicle is intact, clamp ihe axillafy artery through a
sgpil3lCjlll3gbllg.Ulqr incision Howevet it you temoved ihe clavicle, you
hive an extensile inclsion ihat can be cary'€d laterally toward ihe
aeltop"ctoil $ooi66 ""pise the axillarv artifi=_
The damage conttoloptons for an injLlred subcavan ariery afe llgation
or lemporary shunt ing. Boih wofk Ligauon is usual ly wel l toeraied i f the
iniury has not destroyed the major co!lateral pathways around the shoulder
Adding a pre-emptive forearm fasciotomy is a prudeni move'
lf you know your way around ihe niured subclavian ariery and don'i
have 10 bail out, repaif it Unless dealing with a aceraiion that can be fixed
wilh simple laietal repaif, we again advlse you go directy lor an
intemosition graft. Mobilizing the sott and friable subclavian ariety to gain
enough length for an end-to-end repalr a most never works We isolaie ihe
injured segmeni and clamp ii, define lhe lnjury, do a proximal and distal
F;gady thrombectomy, and lnsert an 8mm Dacron interposition graft We
do noi replace the clavicle after completing the vasculaf reconstructlonr
bul cover the tepair with healthy muscle and soft lissue
Go through the bed of the clavicle if the patient is bleeding
TOP KNIFE The Arl & Croft of Troumo Surgery
The descending tholacic ao*a
The patient wlth blunt lnjury to the descending thoracic aorta is typica tyhemodynamlcally stable and has a coniained mediasiinal hemator.a. Don,tiorget that if the paiieri s unsiable, ihe source of hemoffhage is alnrosinvariably in another analomical compartment, iypically below iheoraprragrn,
Again, if you are not a cardiothoracic surgeon, you are not likely io findyourself in the left chest, face.toJace wiih a bluni aortc injury. Howevef,be famlliar with ihe g eneral tech nrcal principles of the repair. Endovasculart.eatment offefs an effective alternaiive to operaiive repair ofthese injuries.Although stil under evaluation, this nrodalty may become the preferredapproach within the next few years.
The classic blunt aodic injury, locaied immediately distal io the take-offof ihe left subclavian artery, is repaired through a left posierolaieralihoracoiomy in the 4th ntercostal space wih single lung ventilation. Themajor palhophysiological chailenge is central hypertensron caused byproxmal aort ic c lamping. Pharmacological agents, a passive shunt, orpump-assisled atriofemoral bypass, typica ly using a centrifugal pump andno hepann, are your optrons.
The technical difficulty in ihis operation siems from the close proximityof ihe aortic tear to the origin of ihe subclavian adery. The pleura overyingthe proxima eft subclavian artery s opened, and ihe adery s encircied byblunt disseci ion. Using a combinaton of sharp and bl !nt disseci ion, ihesurgeo. then encircles the aorta between the left subcavian and eficaroiid arteries, creatingjusl enough space to accommodate a clar.p. Thekey maneuver is developing a plane between the lndersurface of theaortic arch and ihe pulmonary artery. Dista control is obiained byencircling ihe drstalthoracic aorta above the diaphfagm.
After clamping, the hematoma s entered and a careful longiiud nalaortotomy allows the surgeon io assess the extent ofthe njury and decidebeiween primary repair (feasibl€ in roughly 15% of cases) and Dacrongraft inlerposition.
I
I
13 Thorocic vosculorTroumo tor ri'e ceneror'surseon $
) Do a left anterolateral thoracotomy for cardiac gunshol wounds
) Inflow occlusion is your ultimato weapon in cardiac trauma
> Epinephrine is the enemy of the myocardial suture line
) Tying sutures is the challengowhen sewing heart.wounds'
> Use quick and qimple golulions for complex cardiac injuri€s .
> Follow a trailof saf€ty in exploring an uPper m€diastinal hematoml'
) Nover plunge blindiy into the msdiastinum in blunt trauma - '
) . Usq D4gr-arriQr tharacic outlet arterial teconstrucJions i
) The phrenic nerve is your k€y to th€ subclavian artery
) Go through the bBd of the claviclo if th; patient is bie€diirg'
IOP KNIfE The Ari & Croft of Troumo Surgery
Chapter 14
The Neck:SaJari in Tiger CountrY
Go to the heart of dange4 fot therc you will find safetq,
- Old Chinese proverb
The wounded neck is the anatomical 'tiger country," a group of viial
midline struciures tighty packed together, carrying a large neurovascular
bundle on each side. This delcate anatomy is jusl sitiing inside a lafge
hematoma waiting for you to make a wrong move Even surgeons with
eleciive experience in the neck w ll be chaLlenged by a rapid y expanding
cervical hematoma ihat obscures key landmafks and dlstorts the anatomy.
To avoid geiting lost in ihe injured neck, use the trail of safety, a well
defined sequence of steps thai carefully guides you from one key
anaiomical landmark io the nexl without getting losl of causing iatrogenic
damage.
TRAIL OF SAFEW
Jugulafvein
W1W'7@=Follow a trail of safety in neck exploration
TOP KNIfE The Ad & Croit oi Troumo Surgery
Before you begin
Always position the paiient yourself. lmproper posilioning can turn astraightforward neck exploration inio the safar from hell. Support lheshou ders on a shollder roll, and use a head support to exlend and fullyrotaie the head to the other side. The superior med asiinum is an extension
ol the neck (Chapier 13), so your operatlve field extends from the masto dprocess io the upper abdomen and includes both neck and chest. Neverbegin a neck explofaiion without a fulL set of vascular nstrlments, andremember io prepare a site for posslble vein harvesting from the leg
Making the incision
The ut ty incision for neck exploratLonruns aong the anterior border of thesternoc eidomastoid muscle (SCM). Youcan ei(elrd lt from the masioid processio ihe sternal notch, but a morc limitedinclsion is usually good enough. lf youmust go a ihe way io the sternal notch,you may be dea ng with a thoraclc ouiletlnjury where proximal conirol must begained n the chest. As you approach iheangle of the mandibe, curve yourincision posieriorly to avoid ihe marg nanrandibular branch of the facal neNe.
The f i rst layer you encounterbeneaih the skin is ihe platysma. Asit is div ided, the edges of the nclsonopen, and you are ooking for theanierior border of the SC[,4, your firstlandmark on the trail of safety. Thismay not be easy in an injured neckwith an expandlng hematoma.
I
(-,
(
l4lhe Neck: Sofari in Tiger CounTry
The most common pilfall is nraklng your incision ioo posterior lf, upon
divldlng the plaiysma, you bump inio longitudinal muscle fibers' move your
disseciion anteriorly Gaining ihe anterlor border of the SC['4 is more
irnponarl t ral ga n ng tre midhle 4 alaparolomy incisiol Asyou€ppy
o"fiU"rut" uu"oo. *nif" voLr ass'sIant apprres coLrnten'actro'l the incision
almost opens ilself.
Gain the anterior border of the sternocleidomastoid
Develop youl work space
Free the anterior border oJ ihe SCIM by pulling it toward yo! and Inserl
a self-reiaining retractor beLow ihe muscle to keep the wound open Th s
ls lhe firsi step in develop ng your work space
You are now dissecting ir
ihe nriddle cervical fascia, theLayer of areolar tissue beneaththe retfacted SCM. Yout aim isio ideniify the inietnal iugularvein (lJ), your next landmatk onthe trail of safeiy.
The lJ is the most commonlYinjured vascular structure inihe neck. Temporari lY controlbleeding from this vessel wiihyour finger or a small side-brtingvascular clamP, and rePair itLrsing a 5:0 PolYPfopylenesuture. Dont hesitaie to lgateihe vein l f repair is notslraightfoMard. lf the U is notinjured, siay focused on fis
anterior border, which leads to
the nexl landmark on the trall ofsafety - ihe faclal ve n
TOP KNIFE The Art & Crofi of Troumo Surgery
The facial vein is thegatekeeper of the neck, thekey landmark you mustidentify, clamp, and ligate toopen the way 10 the carotidbi furcat ion. Ligat ing anddividing it also allows you tocont inue developing yourwork space by repositioningthe self-retaining retractor ina deeper layer so it pushesthe U out of your way. Yollare now drreclly on top of ihecarotid artery. In mostpaients the facial vein is alsoa convenient marker for thelevel ofthe carotid bifurcation.
In the presence of a large hematoma, taking the necessary time todissect out the facial vein s a smart move, even if you are in a hurry. Keepin mind thai some palienis have 2-3 small veins instead of one large facialvein, and all must be identified and divided along the anterior bofder of theU. A classic pitfall is mistaking the lJ {or the facia vein and lgat ng it, onlyto make the drsseciion more difficult. You have negolialed Ihe trailof safetythrough the injlred neck. li's t me to begin the nexi part of yolr operatoni Iidenlifying and fixing the lnluries.
i
The facial vein is the gatekeeper of the neck
The injured carotid
Gaifiirrg cotlttol
The cardinal prlnciple of obtaining proximal contfol before enieing ahemaloma applies to carotid ariery injury and means isolating the vessel invirgin territory pfoximal to the hematoma. You may occasjonally have to
l4 The Neck:Sofor i in Tlger Country
ertend your incision to thesternal notch or even rnto anredian sternotomy toobtain safe proximal
control. Once inside thecafotid sheath, find, identiiy,and protect the vagusnerve. Encircle the commoncarotid ariery with aRurnmel tourntquei andproceed with dissectiontoward the area of injury
How about dislalcontrol? This is ottenproblemaiic because acervical hematoma typicallyexiends up io the angle of
the mandible (Chapier 3). Therefore, gaining dlstal control outside the
hemaloma may not be possible lnstead, prepare to gain distal conttol
from wlthln the hematoma. lf you are ready for ii, you can control back
bleeding from the iniernaland exiernal caroiid arteries with minimal loss of
As wiih any other named artery in the body the safe plane along the
carotid that protects you from mischief is the periadventitial plane (Chapter
3). As you reach the injury, you encounter back bleeding from lhe internal
and exiernal carotid arterles. First, use your fingef for temporary conirol
Then, eiiher clamp the distal artery or insert an intralunrinal Fogarty
catheter connecied to a 3-way stopcock into the outflow tfact. Remember
that the hypoglossal nerve cfosses over ihe proximal internal caroiid, and
the vagus nerve lies just behind it You have come to the heari ol tiger
country, so stay in ihe sa{e periadventilial plale and bluntly push asrde
(rather than cut) any unideniified struciures Definitive control of ihe
carotid bifurcation means occluding all thtee vessels: the comrnon'
internal, and exlernal carotid arteries
TOP KNIFE Ihe Art & Crofi of Troumo Surgery
Once you have control of the lnlured carotid, lalk to the anesthesiologyteam lo assure the patient has a good blood pressure (a mean of ai least100mmHg) while the carotid is clamped. This is even more critical ifbackflow from the internal carotid is not very brisk.
Stay in the periadventitial plane of the carotid
C arotid f ep &its siflxplified
The carotid artery olayoung healihy aduli s surprisingly soft and pliableand doesn'l toleraie abuse. Unless you are very gentle, you will end upwiih a lorn artery or a repair ihat looks like a dog's breakfast and has to
There are many cool trcks for repairing the carotid artery, incudingsuch soohisticated maneuvers as transDosiiion of the mobilized externalcarotid to connect it to the disial internal carotid. We advise you lo keep iivery simp e and forgetthe coo siuff- oryour pat ient wi lpay the pr ice witha stroke. use ihe simplest and fastest means to revascularlze the bra n.
Are ihere damage conirol options for a carotid injury? Definilelyl Wehave no personal experence wilh temporary shunts in the carotid, bui rtmakes perfeci sense. lf the patieni s about to breach lhe physiologicalenvelope or there are olher mofe life-threatening injuries, ligation is a validoplion. When considering igaiion, remember lhe d tierence between ihecommon and inlefnal carotid arteries. Ligating ihe former is often welltolerated because the interna carotid remains perfused by backflow tromthe exierna cafoiid. Ligaiing lhe internal carotid, especially in ahypotens ve palient, caffies a significant risk of stroke. You may decde lolake that risk to save the patieni s life. Ligation s your only realistic optionfor inaccessible rnternal carotid injuries in Zone lll. Some surgeons ligateihe internal carotld ariery if lhe patent has a profound neuroLogical delicit(coma), while oihers reconslruct il regafdless of the patient's neurologicalsialus. The prognosis rs going to be very poor rn efher case.
l4 The Neck:5ofor l in Tger CounirY
What are the definitive repair opiions? On Tare occaslonsi a clean
laceration (usually a stab wound) may be amenabl€ to simple lateral repair
or end{o'end anastomosis. In most cases we use a synthetic graft or
Datch 1o r€constructthe carotid. We rarely use vein because it takes more
iime to harvesi and prepare, and there is no good evldence thatthis makes
the slighiest diff erence.
Begin by exploring the injury. Open the arlery longitudinalLy in ihe lniured
areato define thefullexlent ofihe damage Caretully debride the coniused
or iniured segment to oblain heallhy aderial wall wiih a normal intlnra on all
sldes of the arterial defect. As you define the injury plan ahead
Precisely define the carotid iniury
Your nexl step is thrombectomy to clear ihe inflow and outflow tracts
Carefully pass a No. 3 Fogarty balloon catheter proximally and distally.
Don't push the caiheter dlstally more than 2-3cm pasi the bi{urcation -
diving ii through ihe carotid siphon will have spectacular results Flush the
proximal and distal ends of the injured artery wilh heparlnized saline and
begin the repair. lf inseriing an interposiiion graft, do the disial
anaslomosis firsi, especially if you are hooking up io the iniernal carolid
above the bifurcation. lt is difficultio work on the posterior wallofihe distal
anastomosis when the proximal anastomosis is akeady sewn in
Whal should you do if there is no backflow from the dislal Internal
carotid ariery? This is a conitoversial poini. We prefer to hgate the artery,
lor fear of convertng an ischemic stroke into a hemorthagic one Some
surgeons feconstruct the artery regardless of backflow
lf you have experience with elective carotid surgery and know how to
smooihly insert a shunl and work afound it - consider do ng just lhal A
shunt is a smart move, especially if backflow from lhe iniernal carotid is
weak or reconstruction is going io take iime Thtead your shunt through
the lumen ofthe lnterposition graft before insedion, and do the€niire distal
and mosi of the proxlmal anastomosis with the shunt in place
TOP KNIFE The Art & Croft of Troumo Surgery
A carotid injury in Zone lll is uncommon and should ideally be idenilfedpreoperaiive y when youf control options are eiiher a Foley balLooncaiheter nserted into the missile tract or angiographic occlusion.
But what if yo! encoLnier a high iniernal carotid injury duflng an urgentexploration? You cannot reach the dlstal internal carotid without optimizingyour exposure. In the presence of relentess back bleeding, yo! have noiime for e aborate maneuvers such as subluxafion of the iaw Your best betis a rnuch simoler alternative - a muscular and deiermined assistant armedwith a suitable retractor Extend your incision to the mastoid process,insert a retractor inio the upper corner of the wolnd, and have yourassistant p ul rea ly hard, giving you a few cr iical mi limeiers. lf this is notenough, divide the poster ior bely of the dgast ic musce to gan more
When all you can see s thebleeding orifice of the iiternalcaroiid, lgation ol the ariery isyo!r only fealistic opiion. Theinjury is simply too high forreconslructon. l f there isn' ieven enough length to ligateor appLy a melal c ip, cons derinserting a Fogarty catheterinio the beeding or i f ice andinfaiing it. Apply iwo metalc ips across the catheter verycose to lhe bal loon, and culthe catheter proximally, leavingthe permanently inf laiedballoon insde the artery. ltmay not be the most eleganisol l t ion ln ihe book - bui i i
Ligating the carotid is not I crime
l4 The Neck:Sofor i in Tlger Colniry
Exsanguination f rom bone
Have you ever seen exsanguinat inghemorrhage Jrom a hole in a bone? This is how a
vedebral artery iniury often presents in the openneck. In the era of liberal angiography, ihis should
be a rare si iuai ion because the prefelredrranagerent ol velebral arterv i ' r lu. |es isangjographic, not opetat ive. Occasiona ly,however, you will discover ihat the cafotid sheathis Inlac- wl i le audible ane' idlbleedrng 15 spuningfrom a hole in ihe pafaverlebral muscles lateraland posterior to il. Feel for the bodies of the
cerylcaL veriebrae to orieni youtself, and you will realize that bleeding ls
coming from the area of the iransverse processes lf you swipe theparavedebral muscles laierally with a Petiosteal elevaior, you are met wth
ihe !nforgetiable slght of bdsk hemorthage from a hole in a bone' ihe bone
being the transverse ptocess of ihe iniured ceruical vertebra
The several ingenious technlques described for this exotic injury are a
sure sign lhal many crealive surgeons have found ii a bafiling ptoblem
Unfooling ihe injured artery in iis bony cana is a demanding technicalfeat
even under the besi eleclive circumstances We certainly don'tconsder ita feasible optlon in a bleeding patent,
and neither should you. Proximalconirol of the injured artery ai ihe baseof ihe neck will not conirol backflowfrom the brain.
Here, aga n, the simp est solulionis ihe besi. Pushing a piece of bonewax inio the bleeding hole usuallyworks like magicl lf your facility hasangiogfaphic capabilities, immediatepostoperaiive angiogram wiih embol_ization of the injured vertebral ariery is
anothef option.
Use bone wax to plug a hosing vertebral artery
TOP KNIFE The Art & Crofi of Troumo
The esophagus
SLrrgery
There are two routes iothe cervical esophagus,going ei ther medial orlateral to the carotidsheath. The nredial routeis a natural continuation ofcarotid exploratron andprobably the one whichyou are most far.iliar wiih.
Before exploring theesophagus, ask iheanesthesiologist to inserta large-bore nasogasirictube to help you identify the esophagls by palpating the tube in a hostileoperative field. The esophagus is located slighily to the left of the midline,making it easier to explore from the left side of the neck.
Retract ihe conient of thecarotid sheath laterally and enterthe plane between it and thetrachea. You wi l l f ind theesophagus behind lhe t facheaand anieror to ihe spine. Ful lexposure of the esophagusrequires you identify and dividethree structures ihai cross overthe esophagus: the omohyoidmuscle, middle thyroid vein, andinfer or thyroid ariery. Therecurrent laryngeal nerue is rarelyidentified in the jnjured hosiile
l4 The Neck:Sofor l in Tlger Cowiry
The other approach to the esophagus, going lalerallo ihe carolid adery,
is a "back door" approach, Llseful when a large hemaioma in the caroiid
sheath obscufes ihe anatomy Retract the caroiid sheath struciufes
medially insiead of laterally, and enier ihe plane between the carotrd
sheath and the cervical spine to find the esophagus Your work space is
limited, but you are Iess likely io cause iatrogenic damage.
Approach the iniured esophagus th.ough a fiont or back door
Esophageal lniuties are noi easy to idenlify because the esophagus
doesn'i have serosa. lf you can'l be sure there is an injury, goide the
anesthesiologist to pull ihe nasogastric tube to the level of your
expLorai lon, f lood ihe operat lve f eLd with saine' and ask the
anesthesiolog st to inllate ihe nasogasiric lube with air' Waich for
emerging air bubbles.
The most worrisome aspect of an esophagea exPotaiion is noi what
you can see and feel, bui what you cat'l Is there an injury to the other side
ol ihe esophagus? To ihe posierior wal? Wiih limited exposure, it is easy
lo miss such an injury. lf you suspect a hoLe you can 1 see' nere aro your
opl ions:
a Contralateral neck exploration through a separate incsion'often your
a Intraoperatve esophagoscopy lo look for an iniury lrom inside ihe
lumen,a Mobllize the esophagus by bluntly developing the plane between it,
the tfachea anieriorly, and the anterior longitudinal igaments
posteriorly. Hook your finger (or a Penrose drain) around it and
inspecl the contralateral and posteriof aspects However, this
maneuver s more dltficult lhan our description leads you to believe'
especialLy if you ate trylng to do il thro!gh a right-sided neck incision
Unless you have deceni experience with esophageal surgeryi don t
use lhis option. You may cause iairogenic iniury to the esophagus and
fecurrent laryngeal nerves, as well as devascularize the irachea
TOP KNIFE lhe Ad & Croft olTroumo Surgery
Regardless of the option you choose, the key tacucal princip e is io besure about the hidden aspects of the esophagus before conclud ng youfexDtoTaIlon,
Worry about the hidden aspects of the esophagus
After identifying an esophageal injury, careiully assess the extent ofdamage. [,4ucosal damage is ofien more extensive than ihe apparent injurylo the muscularis. Conservatively debride the wound to obtain healthyedges on all sides and repair it using one or lwo ayers, Our preference isa single layer repa r using an absorbable monofilament suture, [,/uch moreimpodanl than the number oi layers ls precise definlton and meticulousaDoroximation of the mucosal deiect witholt tens on.
Always isolate your esophageal repair from oiher suture Ines. lf youhave also fixed ihe caroiid adery or the irachea, remember that theesophagea repa r s the one mosi ikely to fa L When il fails - lt may takeyour other repa rs wih it. Don t et it happen. lnierpose a well'vascu lar zedchunk of healthy rnuscle between the esophag!s and any adjaceni suturelines. The strap musces, ornohyoid or slernal head of the SCM can eachbe transected close to their inferior attachmenis and ihen used to keepvour suture lines safe v aoart.
Whal is ihe danrage control optior for the cervical esophagus? Srncethe aim is to prevent an uncontrolled eak, the bail oui soluton ls exterraldrainage. l f the injury is naccess ble (e.9. high or poster ior in thehypopharynx), just drain t. lf there is no distal obstrlciion, the fisiula wilrapid y close.
When you cannot safely close the deiect because it is loo large, theoperaiion was de ayed, or you have to bai out, either drain or exteriorize itas a latera esophagostomy. This s pariicuLarly relevanl when youencounter combined njurles to the esophagus and lrachea, wherecreat i fg two high-r isk suture lnes is asking for t roube. Repair ing theairway and divertrng ihe esophagus may be a safer option.
A quick and easy bail out optior that has worked for us is to rnserl alafge suctjon drain irio ihe defecl, rapidly purse'siring the esophageal wall
Bail out by creating a controlled esophagealfistula
14 The Neck Sofori in Tiger Counlry
around it and bring ii out ihrough the skin Whatever you choose as your
damage control solution, fememberl an uncontrolled esophageaL leak
means mediasiinitis and death; a controlled flstula means a longer hospLtal
stay with a good chance ot recovery
The larynx and trachea
lnjuries to lhe upper airway come in two lypes: small and large Repairsmall aceralions of the larynx and trachea with interrupted 3:0monofilament absorbable sutures tied on lhe ouiside Never use non-absorbable sulures to repaLr the alrway.
Large defecis cannot be simply approximated withoui ienson because
part of ihe cariilage is missing. To obtain a good outcome' you are well
advised to gei early help ffom an ENT colleague They have more
experience with the upper airway and will ultimateLy rnanage any
complicatlons.
Several damage control oplions for uppef airway inluies are availabl-".
You can simply push ihe endotracheal tube Past the injuted area to
eliminate the air leak, leaving the injury alone fof a delayed reconstruciion
Another oplion is tracheostomy. Inserting a itacheostomy tube through a
traumatic tracheal defect is not a good move under elect lve
circumstances. li is, however, perfectLy accepiable as a bail out option
when the pat ient has other i fe-threatening iniures, orwhenyou ate facing
a comp ex Inlury on your own.
Transcervical iniuries
How should you approach a peneirating injury that crosses the neck
from sldeio-side? Transceruica! injuries may require biLaierd expLoraiion
Ruling out an injury to the oiher slde of the esophagus or trachea by
ir t faoperai ive endoscopy, whi le iechnical ly possible, is logisi ical ly
TOP KNIFE The Ari & Croit of Tfaumo Suraelv
To explore a transcervicalpenetration, we prefer a lJncjsion, the ceryica equivalentof a clam-shel thoracotomy. lfyou spend a few minutesdeveoprng a superror skin fap inthe subplaiysma plane (as youwould do in a thyroidectomy),you gain maximalexposure of ihebilaieral neck, mlch like iftingthe hood of your car to look ailhe engine. Exposure justdoesn't get any better than this.
Lift the hood off the neck with a U incision
Finishing up
Have a good look at the edges ot your ncision in search of superlicalbleeders. In the neck, a smal muscular bleeder can easily lead to apostoperaive expanding hematoma and the need for urgent re-exploration, Inspect your suture lines and make sure they are nicelyseparated by viable muscle.
We strongly advise you dra n every neck exploration {or lrauma using aclosed suction drain. The mosi commonly mlssed injury in the neck is asmall esophageal perforaiion. Your dra n will conved a poientlal disasterinlo a minor problem. Jf drain ng an esophageal suture l ine, br ing yourdrain out anierorly wiihout crossing over the caroiid artery'drains havebeen known to erode into lt. The only ayer you have to approximate deepto the skin is the plaiysma. Then cose the skin and you have successfulycompleied your safari in tiger country.
\ - l\\.r11
II
t14 Jhe Neck Sotari in Tigea'CoLtniy
)
)
)
)
)
)
)
)
)
) Lift.the hood off thensck with a U incision
TOP KNIfE lhe Art & CrclJi of lroumo SLJrgery
Chapter 15
Peripheral VascularTrauma Made Simple
Eoerything shoulil be fia ile assimple as possible, but not sirftpler.
- Alberi Einstein
li you think you know whai a bloody mess looks like, a close encounter
with a hosing groin wi I have you think aga n The patient is n shock, with
most of the bLood volume eilher lelt at the scene or all over ihe paranredlc
compressing the bleeding gfoln for dear life. Since ihls is one oJ the most
spectacular penetrating injuries, ii is easy to forgei priotities, r.ake critical
errors, and lose ihe patlenl in the midst of the chaos
In ihis chapier we try to bridge the wide gap between the neat
ilustrations of vascular exposures you see n books and the harsh teality
of the OR, where the paiient is bleeding and all you can see in ihe
operative field is tfaumaiized muscle and lots of hernaloma. Bridging th sgap is especially important for surgeons who don t do periPheral vascular
work on a regular basis but are called upon to conifo and repair the
occasional arterial injury. Our key message is that the injufed artery is
always part of a wo!nded patienl, and the patient's overalltrauma burden
oflFn orcraies 1ow yoJ approach lhe vdscu ar 'njury
Caining control of the hosing groin
Obtain iemporary control of ihe bleedlng groin wiih local pressure
applied by an enthusiasiic assistani or a Foley calheter in the tract Once
in lhe OR, you need proximalconlroland have three opt ions:
i Laparoiomy - if there is urgent indicaiion, go into the abdomen and
control the ertFrnal iliac anery in the pclv;s
TOP KNItE The Ari & Croft of Trouma Surgery
a Reiroperitoneal approach -
expose the exiernal i|acartery through an obljquelower abdor. inal lnclsronapproxrmately 2cm abovea.d pafal lel to the nguinall igameni. Incise the apo-neuroses of the external andinternal ob|que, and openthe iransversls abdominisand transversalis fascia ioexpose the preperitoneal fat.Gentle cephalad retraction ofthe peritoneal sac will bringyou to lhe external iliacartery. This approach avoidslaparotomy, but takes time,so is farely used in thebleeding patieni.
a Verticalgroin inclsion - the simplest way to gain p roximal control of ihenosrng grorn,
So much for the good news. The bad news is that even with proximacontrol, the paiient continles to beed, albeit at a slower rate. lf backbleeding is noi very brisk and you can identify the key structures, use acombinaton of sharp and blunt disseciion lo expose the fer.ora vessels.Blunt disseciion is saler in hostile terriiory. You want to avoid damage tothe femora nerve, and yo! cannot cut the femoral nerve wiih your finger
lf you can t see what you're doing because ol brisk back bleeding, walkthe camps (Chapter 9). The solrce of persistent back bleed ng is oftenthe deep femoral artery that must be identifed and controlled. When yousucceed, breath a sgh of relief; you have successfully deat with one ofthe cobras oi traurna sufgery.
Gain proximal control of the hosing groin
l5 Peripherol vsscu o. Trounro Mode Simple
A quick tour of the femoral tdangle
You are pfobably {amiliar with
the femoral triangle from visrts 1olhe groln in elect ive vascuarprocedures. Make a vertical skinincision over the femoral pllse, ifpresent. otherwise, place yout
incision halfway between thepubic tubercle and the anteriorsuperior lliac spine. Approximatelyone-third of the incision shouldextend above the gfoin creaseThis is not the time to be hesLtantor minimally invasive.
Exposing the femoral vessels in awar zone is not easy. You have toidentify and incise iwo fascial layers:the fascia lata and the femorasheath. Cut lhe {ascia latalongitudinally lo enter the fat of thefemoral triangle and insert a self-retaining retractof. Your best friend inthe hosi i le groin is the inguinall igament, and the exPeriencedsurgeon makes a poinl of idenii{yingt early. Palpale the faity content ofthe triangle with an educaied IingerFeel for a pulse or, if absent, for a
tubular structure in the fai ln thepulseless groin, you often encountermuscle beneath the fascia lata. Thissimply means thai you are too latera,over the iliopsoas muscle, so redireciyour dissection medial )/
The inguinal ligament i5 your only friend in a hostile groin
TOP KNIFE The Art & Croft of Troumo Surgery
Next, open ihe femoral sheaih io jdentify ihe femorat artery. Repositionihe self-retajning retractor at a deeper level or add another retractor. Stayon top oi the artery in ihe pedadventitial plane. lf you deviate r.edially, youmay be greeted by a gush of dark blood from the fer.ora vein. If vou stravlaterally, you may injure the lemorai nerue.
lsolaie and control thecommon lemoral artery and iisbranches. While the commonand superf ic ial femoralarter ies can be readi lyidentified and encircled in theproxmaland distalparts of theincision, isolat ing the deepfemoral artery can be difficulifor surgeons with few 'groin
hours. ' The lateral femoralcircumflex vein is ihe mostkeacherous vein in the groir.It crosses immediately in froniof the proximal deep femoral artery in ihe crotch between the deep andsupedicial femofal artery. lf you try to expose the deep femoral artery byunroofing it, you soon encounter brisk venous bleedino lrom ihe iniufedvein. Avordils-rhis ;i6;iJiiiiruaTioi-ii rar'tctei ihan tryirg to.ix ir. oonot disseci out the deep femoral artery, plain and simptel
The origin of the deepfemoral artery is marked by anabrupi change in the drameterof the common femoral artery.Take a vessel ioop and passone end from lateral to mediaunderneath the commonfemoral artery weli above ihebifurcation. Grab the other endof the loop and pass it frommedial to lateral well below thebifurcation. Lift up both ends of
I 5 Perlphero Vosc ulor Troumo Mode sim p e
the loop io discover thai you have neatly isolated the deep femofal afiery
without dissecting it out
Getting aro!nd ihe groin is r.ore difficult in the presence of a szeable
hemator.;. We call it a hosiile groin, and when you come face_to_face wiih
it, you willsee why. The anatomy is distorted' the tlssues are suffused with
blood, and a bu ging hematoma is look ng up at you in toial defiance
Here, we would like io lei Yotrln on a litlle trade secrei Forget
lhe femoral vesselsl Instead,focus on f inding ihe inguinalligameni. lt sounds crazy _ blt t
works. The inguinal ligament s
an anatomical barrier {ChaPler3), and i{ you ldentiry the lower
edge of the ligameni and cul ii,you willfind yourself in the virgin
lower reiroperitoneum. Now,you can easlly ideniify ihe
exiemal iliac vessels immediaiely
above the groin.
There is, however, a less destrucilve way
to clamp lhe femoral vessels above the
inguinal gameni. Take blunl Mayo sclssors
and make a hole in the inguinal ligameni
approximately 1_2cm above and parallelio iis
edge. lnseri a nafrow dsep reiractor io keep
the space open. This brlngs you into the
hematomaJfee retroperiioneum wLthout
dividing ihe inguinal ligament You can now
use ihis hole io easily palpate and sa{ely
carnp lhe externalllac ariery above the groin.
Allthis is very cool, bui if you are pressed ior
iime and ihe groin is aciively bleeding, don t
Don't dissect out the deep femoral artery
TOP KNIFE The Ari a Croft of I roumo Su gery
hesfiate to cut ihe inguina] Iigament. lt is a small price io pay for expedieftprox mal conlrot,
Control the common femoral artery through the inguinal ligament
Considering youl options
As in any other operation for trauma, you now have to choose anoperative profile. Consider ihe patieni s ovefall trauma burden andphys ology, as well as the operative circumsiances (Chapter 1). Are youoperatrng rf a university trauma center or in an mprovised field hospital na war zofe? How comfortable are you with vascular work? Balance allthese against the feparf optrons.
Darnage coniro options for ihe femora vessels are temporary shuntingor ligaiior. A temporary shunt i. the common or superficial femoral arteryis an excellent damage conirol so ution to maintain distat perfusion. Westrongly recomr.end you do a pre,emptive fasciotomy to give the legadded prolectron in case of early shunl fallufe (Chapler 3). On v6ry rareoccasions when a shuft is not an opUon, ligating the lemorat artery is avalid aiernatve. In fact, you can igate the slpedicial femoral artery in ayoung healthy paiient with low risk of llmb loss, pfovided collateralciculation via the deep femofal artery is irjtact. In the greai nraioriiy of bailout siluations, a shunt is a nruch better option.
When operai ing ln damage controlmode, f ix the femoralvein only i fyoucan get away with a simple latera repah Don t hesitate to ligate ihe veinif the injury req!ires an),thing rnore elaboraie.
Shunt + fasciotomy = bail out fo. femoral artery iniuries
Preserving the deep fenroral artery when possible, is an impodantprinciple. Your ability to reconstruct ihe bifurcation depends on yourvascu ar expefence and technical repertoire. One welfknown trick in the
r5 Perlpherol vosculor Troumo Made slmpe
face of extensive damage tothe bifufcation is to join thestur.ps of the superflcial andde6p femoral arteries side{o-side to create a short commonarterial trunk before insertingan nterposlt ion graft . Thisspares you the awkward job ofimplaniing the deep femoraartery lnto the gra{i.
lf the posterior wall of iheinjured ferioral artery rs iniact,do a patch repa;r lf the arteryis transected, in ierpose asynihetic grajt or a reversedsaphenous vein fror. the oiherleg. lf the arterial and veirous suture lines afe immediately adjacent,
interpose viable muscle belween them to prevent an aitoriovenous fisiula
We do not lnsert iniePosition grafts lnto the femoral vein, but many
surgeons oo.
Whatever yo! do to fx ihe femoral vessels, plan your reconstructLon
wilh soft iissue coverage in mind lf you cannot cover the arterial
reconstructon with well-vasculariz€d soft tissue (e,g swinging the
sarioriLrs muscle over the repait), call someone who can An exposed
arterial suiure line is a ticking time bomb that will blow up in vour tace
An exposed vascular suture line is a ticking time bomb
The superficial femoral afiery
Not surpris ngly, a descr piion of superficial femoraL art6ry exposures is
not found ir most vascular surgical atlases because it is rarely lsed in
electve surgery. Here's how it's done.
I
A , A
TOP KNIfE lhe Art & Crofl of Trourao Suoerv
Sl ight ly f lex andexternally rotatethe pat ieni 's eg,supportrng t onfolded towels. Whenworking above iheknee, support iheleg below the knee to avoid disiorling your work space. Make a longitudinalincision over the anterior border ol ihe sartorils muscle, extending it wellproximalto the injury. lncise the skin carelully to avod accidentally transecting
the saphenous vein. Openthe superficial fascla andidentify the sartoriusmuscle, the gaiekeeper ofihe super{ ic ial {emoralartery. Retract ihe sadorius,eithef anieflorly (in theupper and niddle ihigh) orposterrorly (in the middleand ower thigh), byinsertlng a self.retainingretractor nto the wound.Your target ls the flbrousroof of Hunter s canal, the
white fascia directly underneath the sartorius between the adductormagnus and vastus medialis muscles. Open il and you are staring at theneurovascular bundle. Carefully free the superficial femoral artery from theadjacent vein and payspecial atteniion to thesaphenous nerve that Lspad oi the neurovascularbunde and can be easi jydamaged. As with anyvascu ar Injuryi $an yourdissection ln v rgin terriioryproximal to the injury andproceed disialy towardthe injured segment.
What are your repair optons? YoLl may elecl to insert a shunt if you
need to bail out or if you decide (with ihe orihopedic surgeons) to achleve
bone alignment prior to arterial repair. This is genetally a good idea since
sewing a graft in an unslable flailing lir.b is something yo! should avoid lf
possible. When the superficial femoral artery is iransected' Insert an
interposition graft.
The sartorius is the gatekeeper of the superficial femoral artery
Popliteal repaks the easy waY
Treat the popliteal artery wiih the resPect it deserves lt is the leasl
accessible vessel in the lower ex?emlty, and ihe collaleralflow around the
knee is insufficenito sustain viability ofthe lowef leg ifflow in the popliieal
artery is inierrupted- Even ioday, poplitea artery trauma catries lhe h ghest
inb loss rare o'ale\kemry vascuar nrures.
Always begin a popliteal repair with {asciotomy, even il you are an
exiremely smooth operatof. lf there are no associated lnjuries ihat may
bleed, give systemic heparin. [/any pop iiealrepairs fa because ol cotted
dista mlcrocirculation, not because of a technlcalflaw
Treat the iniured popliteal adery with the greatest respect
The safe and soundroute to ihe injuredpopliieal artery is themedial approach. Makean incislon in the lowerth gh along the palpablegroove belween thevastus medials and sart-orius muscles. Palpate
l5 Peiplrero Voscu or Troumo Mode Simp e
the posterior border o{ ihe femur and incise ihe deep fascia posterior to ii,
bringing you s?aight into the fatiy contentofthe popliteal lossa. lnserl a fingerand palpate the pulse of ihe popliteal artery againsi the posteior aspect of
TOP KNIfE The Ari & Croii of Troumo Surgery
the fe.nur The posterioredge of lhe bone is the keyanatomical landmark toidentify ihe popliteal vessels,both above and below theknee. Now ideniify, dissectout, and enc fcle the above.knee popliieal artery. Thethree major pitfalls in thisdissection are injuring lheclosely adherenl poplitealvein, cutling the saphenousnerve, and mislaking the
Find the popliteal artery immediately behind the bone
Expose the distal
Pophteal segmentthfough a sepafateincision that runsapproximately lcmbehind the border ofthe tibia, begrnning atthe level of the kneermmediaie y posteriorto ihe medial femoral
Asain, beware of injur ngthe saphenous v€in that liesimrnediately posterior io yourincision. Cutting lhe deepfascra reveals the fal of thedistal poplileal fossa, whereyou find the neurovascularbundle immediately behindthe bone. The first structure
15 Periplreroi Voscu or Trou mo Mode smpe
you encounler is the pop iteal vein, and you have to carefully dissect the
ariery away lrom rt.
So niuch for proximal and distal control. But how are you golng to lix
ihe injury itsel{, an iniury that siill remains hidden behind the knee? Well'
you can do it the hard way or the easy way
The hard way is the traditional ful! popliteal exposlre' the one you
should describe in your Board Exam because ihls ls whai examLnerc
expeci to hear. li entais joining ihe medial incisions above and below ihe
knee and dividing the tendinous aitachn-rents ofihe posleromedialmuscles
(sariorius, graciis, semimembranosus' semltendinosus)' as well as the
attachment of ihe medial head of the gasirocnemius ln praciice' grab the
cauiery and blaze a trail oJ destruciion between your proximal and distal
incisions, blasting any iendon ihal stands between you and the poPl*eal
artery. Ii sounds llke a search and deslroy mission because it is Bytheiime
you flnish, it is not a pretty sight, but you can get io the artery and fix it
There is a simpler alternative lnsiead of exposing ihe injured artery,
bypass and exclude it. You akeady have lhe proximaland distal popliteal
segments looped and ready Even if the popliteal veln s injured' ii doesn't
matter, You don t have to reconstruct it io achleve a good outcome The
notion thai yo! do ls jusi another sacred cow that has been slaughtered
by curreni data. Your mosl expedient soluiion is to harvest a pLece oT
saphenous vein from ihe other thigh, teverce ii, and inseri ii as an
lnterposiiion graft belween the proximaL and dista poplitea artery,
excluding the injured segment.
Bluntly creaie an inter_condyaf iunnel betweenihe proximal and disiallncisions. Do a longiiudinalarteriotor.y in the Proximalpopliieal artery above theknee, hook !p thereversed vein endlo-side,and ihen doubLy lLgate the
adery immediatelY distal
TOP KNIFE The A.t & Croit of Troumo Surgery
to the anastomosis to exclude the inlured segment. pass the pusatinggraftthrough ihe tunnel, and hook it up to a similar arterioiomy in ihe distalpop iteal ariery below the knee. Then ligate the artery immediately proximato the d stal anastomosis to complete the exc usion, In an obese pattentwith a deep artery, ii is easier to transect the proximal and drstal ooplitealarreJ. oversew rhe ends o l -F e.ctLdeo <eg-ent. a. ld .hen hoot up -hevein graft end-io-end.
The huge advartage of this approach is simplicity. you don t have iodeal with the inj!red segment ai all. The on y vatid reason to take down theligaments and expose ihe popliteal fossa is ongoing bleeding from thenjufed segment despite exclus on, a s tuaton we nave yet io encounter
Bypass and exclnde the iniured popliteal artery
Below the knee
Reconsiructing a iibial artery in a patieni wiih a blunt bumper injLrrythai includes a fractured libia and f bula is an experience I ke y to remainetched n your memory. Imag ne spending the beiter part of an on-callnrght trying to bridge two spastc noodles in a soup of blood, brokenbones, and torn nuscl€s. Answering the following ihree quesiions canhe p make this experience much ess traumatic for you and your patient.
1. ls th s escapade really necessary? One of the rhree leg arieries openall the way down to the foot rs good enough. The iradiiionai teach ngthat panents with blunt trauma need two open vessels s anunsubstantiated urban legend. Remember - if one of the three arteriesis beedng, the solution is noi surgical exptoraiion and ligation, b!t,rather, angiographic occlusion ol the bleeder (unless angiography isfoi ava labe).
2. Do you have the required infofmaiiof for a safe trip? Staring avascular explorat ion beow ihe knee wthout a ctear angographicdelineaiion of the inlured segment is tike stading the Dakar Rallywitholt a map. I\,,lake every effort to obtain a formal angiogram. lf you
l5 Pe.ipherol Voscu ar Troumo Mode Simpe
are forced to run to the OR urgenily' begin by exposing the popliieal
artery below the knee and shooting an on_table angiogram A stlb_
optimal angiogram can send you on a lengihy exploration ot what
turns oui to be an intact aitery in spasm3. Where to begin? The popliieal fossa below the knee ls an excellent
siarting point because you can always {ind the ariery there, even if
you have lilte vascular experience ll is v rgin terrltory, the vessels ate
large, and you can ideniify the neurovascular bundle and follow t
disialy.
Retracl the medialhead of the gastroc-nemius posteriorly andexpose the edge of thesoleus muscle archlngovef the popl i tealvessels. Hook a f ingerunderneath the r.usceand detach ii trom thet ibia. This opens thesPace, alowlng you toplace a self-retainlngretfactor in the wound.Proceed distally towardthe injury by takingdown the atlachment of the soleus lo the posterior aspect of the Ubia
Look for ihe anterior tibial vein as a marker of the iake-off of the anienortibiaL artery. FurtherdistaLly, identify thebifurcation of ihetiboperoneal irunkinto the postenorlibial and peronealarteries, where theformer is the moresuperfic al vessel.
Expose ihe anterior tibial artery ln the mid'and lowef leg ihrough youranterior fasciotomy incision, lnsert a self-retaining retractor between thet ibiais aniefor and the extensor hal lucis longus mlscles, and f ind theneurovascu ar b!nde deep down between the musces, on theInlerosseus raemDTane,
Before you begin a vascular exploration below the knee, slronglyconsider us ng a proxima pneumatc iourniquet above ihe knee. Noth ngis more lrustratrng than trying io identlfy and isolate the small and frag levessels of the lower leg in the presence of active bleeding not io meniionihe ncreased rsk of ia irogenic njury io other eements of theneurovascular bundle,
Whch ar iery shoud you reconstruct? Always go lor the moststraightforward so ution n the mosl accessibe ariery and take intoaccount soft tissue coverage. lMost often, th s lranslates inlo reconstruciingthe poster or libial adery. In a badly inj! red eg, be prepared to spen d som etime looking for the dstal end of the transected vessel, which may bedtf icul i 10 fnd. In most instances, your best reconstruct ive opt ion is aninterposition graft using a reversed saphenous vein frorn the other ank e.
TOP KNIFE The Ad & Croli of Troumo Surgery
The axillary artery
To gain rapld access io the,4&iy," ^,--proximal axilary artery, you have io ;r;1 ,r 1, ,.a^or)go ihrough the pectorais majormuscle. Abduct the arm and makean nfraclavlcular incsion extendingfrom the mid-clavicle io thedeltopectoral groove. This trans-pectoral rouie is an extens leexposure. You can extend it distallyalong lhe del lopectoral groove.Dissection between the delioid andihe pectoralis r.ajor, comb ned wilh
One open t ibialartery is good enough
i) ,-.4-' -
lateral revactlon of ihe cephalic vein, will reveal the clavipectotal fascra
containing the neurovascular bundle Fudher distal exienspn Into the
groove between the biceps and the tticeps muscles will get you to the
proximal brachial adery
Cul down io thepecioral lascia, divideit, and then spread thepectoralis major fibersby insedrng closedMayo scissors inio ihemuscle and oPenjngthem pefPendicular toihe fibers lo nrake ahole. Underneath you
find the pectotalis minorand the claviPectoraLfascia medialto ll. OPen
r5 Peiphera voscuarlroumo Mode simp e
.|trr.",r..*,J ,,,y
' q ' . l . J l r - , - i l - ^ r
the clavipecloral fasclaand dlssect ln the axilLary fai to identify the axillary vein, the gatekeeper o{
lhe ar l la. Tl^e anery is oeep and supet ior Io i t To opt 'nize you'worl
space, get the pectoralis mlnor muscle oui of the way either by retractrng
ii lateraiLy or dividing its upper aitachr.ent 1o ihe coracoid process To
safely mobilize the axillary artery, you musi fitst identify' clanrP, and cui the
thoracoacfomial artery, one o{ the only arterial bfanches in the body io
come siraight at you when exposing the pareni vessel
Your damage conhol opiions for axillary artery iniuries are shunt
insertion and, less commonLy, ligation and fasciotomy Ample collaterals
around ihe sho!lder wilL prevent critical distal ischemia in most patienis
wrh an ir .e Jpted ar i ,a-y alery but rFuonstrLcion rusng a saohelors
vein gra{i hawesied from the ihigh) is a betier option if {easible
Approach the axillary artery through the pectoralis major, not around rt
)-'., .,;,..,
TOP KNIfE The Ad & Crofl of Tro!mo Surgery
The brachial artery
The brachial airery s the mostfrequently injured artery in the bodyand certainly one ol the mostaccessib e, Gain access to thepfoximal artery via a medal upperarm incision along the groovebetween the brceps and tr icepsmuscles. This incision sthe epitomeof extensile exposure, as it can beeasiy extended both pfoximally ntoihe de topectoral groove and d stallyacross ih€ antecub talfossa inlo theforearm. Incise the deep fascia atthe media border of the biceps,
i t r . \ . v . / -
taking care to avoldiairogenic lnj ! ry to thebasiic vein as it emergesihrough ihe fascia in ihelowef aspect of theincision. Antefror retractionoJ the brceps will exposethe neurovasc!lar bundleenveloped in the brachialsheath. The f rst siructureyou encounter (and yourlandmark) is the mediannerve. Retract it genlly toget t oui of your way.
Distal extension of the medial arm lnclsion rs vra an S-shaped ncrsioncarried across the antecubital space disia to the skin crease. The distalbrachial artery and its bifurcation are located immediately beneath ihebiceps tendon, again rn cJose proximiiy to the median nerve.
The damage control option lor the brachial adery is ligation and
fasciotomy, which is very welliolerated, espocially i{ the iniury is in the mid_
or distal arm beyond to the take'off of the deep brachial artery The
oefntve repair opton s a veir interpos:t ion gtaft Jsing the sapheroLs
vein harvesied above the ankls.
T H E K E Y P O I N T S
) Gain proximal conirol of the hosing groin
) The inguinal ligameni is your only friend in a hostile groin'
> Don'i dissect out the deep femoral arterr'
) Controlihe common femoral artery through the inguinal ligament
) Shunt + fasciotomy = bail out {or femoral ariery injuries
) An exposed vascular suture line is a ticking lime bomb'
) The sartorius is ihe gatekeeper of the superficial femoral artery'
) Treat the injured popliteal artery with lhe greatest respect'
) Find the popliteal artery immediately behind the bone'
) Bypass and exclude ihe injured popliteal artery
) One open tibial artefy is good enough.
) Approach the axillary artery through the pectoraiis major, not around t
I5 Peiplrero Voscu or Troumo Mocle simp e
'* ll
