Overview
Definition:
Trauma laparotomy for penetrating injury refers to an emergency surgical procedure performed to explore the abdominal cavity and manage injuries resulting from stab wounds, gunshot wounds, or other forms of sharp or ballistic trauma that have breached the peritoneum.
Epidemiology:
Penetrating abdominal trauma accounts for a significant portion of trauma admissions, with variations based on geographic location, socioeconomic factors, and prevailing violence levels
gunshot wounds generally cause more severe injuries than stab wounds.
Clinical Significance:
Prompt and accurate surgical intervention is crucial to control hemorrhage, prevent contamination, and repair organ damage, thereby minimizing morbidity and mortality in patients with penetrating abdominal injuries.
Clinical Presentation
Symptoms:
Abdominal pain
Nausea and vomiting
Hemoptysis or hematemesis if thoracic involvement
Hematochezia or melena with gastrointestinal injury
Diarrhea if intestinal perforation
Distended abdomen
Decreased urine output.
Signs:
Hypotension
Tachycardia
Tachypnea
Signs of shock
Abdominal tenderness, guarding, rigidity, and rebound tenderness
Evisceration of abdominal contents
Distended abdomen
Peritoneal signs
Pulsatile mass in flank
Hematuria.
Diagnostic Criteria:
No strict diagnostic criteria
management is largely based on clinical suspicion and hemodynamic status
indications for laparotomy include hemodynamic instability with suspected intra-abdominal injury, peritonitis, evisceration, or positive diagnostic peritoneal lavage (DPL) or FAST scan.
Diagnostic Approach
History Taking:
Mechanism of injury (stab vs
gunshot, number of stab wounds, caliber and range of firearm)
Time since injury
Associated injuries
Allergies
Medications
Past surgical history
Last meal
Events leading to injury.
Physical Examination:
Primary survey (ABCDEs)
Secondary survey focusing on a thorough abdominal examination including inspection for external wounds, palpation for tenderness, guarding, rigidity, and rebound
Assess for flank or back wounds
Rectal and vaginal examinations in relevant cases.
Investigations:
Complete Blood Count (CBC) with differential and platelets
Coagulation profile (PT/INR, aPTT)
Serum electrolytes, BUN, creatinine
Liver function tests (LFTs)
Amylase and lipase
Urinalysis
Arterial Blood Gas (ABG) in shocked patients
Chest X-ray (AP view) to assess diaphragmatic injury and hemothorax
Focused Assessment with Sonography for Trauma (FAST) scan to detect free fluid in the abdomen
Computed Tomography (CT) scan of the abdomen and pelvis with intravenous contrast if hemodynamically stable and no immediate need for surgery
Diagnostic Peritoneal Lavage (DPL) is less commonly used now but involves instilling saline into the peritoneum and aspirating it for analysis of red blood cell count or other indicators.
Differential Diagnosis:
Non-penetrating abdominal trauma
Intra-abdominal desmoid tumors
Retroperitoneal hematoma from other causes
Pelvic fractures with associated injury.
Management
Initial Management:
Rapid sequence intubation (RSI) if indicated
Large bore intravenous access (two lines, 16-18 gauge)
Aggressive fluid resuscitation with crystalloids (e.g., Lactated Ringer's or normal saline) and blood products (packed red blood cells, fresh frozen plasma, platelets) to maintain hemodynamic stability
Analgesia
Antibiotic prophylaxis (e.g., cefazolin or cefuroxime plus metronidazole)
Tetanus prophylaxis.
Medical Management:
Primarily supportive care, focusing on fluid and blood resuscitation
Vasopressors may be required if hypotension persists despite adequate resuscitation
Early initiation of broad-spectrum antibiotics to cover gram-negative and anaerobic organisms.
Surgical Management:
Indications: Hemodynamic instability with suspected intra-abdominal injury
peritoneal signs (rigidity, rebound tenderness)
evisceration of abdominal contents
retained foreign body causing concern
positive FAST scan with significant free fluid
penetrating wound with violation of the rectus sheath
serial examinations showing deterioration
Surgical approach: Midline laparotomy is the standard for complete abdominal exploration due to speed and maximal exposure
Other approaches include paramedian or subcostal incisions depending on the injury location
The entire abdominal cavity must be systematically explored, including the diaphragm, stomach, small and large intestines, mesentery, spleen, liver, kidneys, pancreas, and retroperitoneum
Bleeding control is paramount
Management of specific organ injuries depends on their severity and involves ligation of vessels, repair of bowel perforations (resection and anastomosis, or diversion), splenectomy, hepatorrhaphy, nephrectomy, or pancreaticoduodenectomy
Damage control laparotomy may be employed in severely injured, hemodynamically unstable patients, involving control of hemorrhage, bowel resection with ostomy creation, and temporary abdominal closure (e.g., with a Bogota bag or vacuum-assisted closure) with planned re-exploration within 24-48 hours.
Supportive Care:
Continuous cardiorespiratory monitoring
Nasogastric (NG) tube decompression
Urinary catheterization for monitoring output
Nutritional support (enteral feeding if possible within 24-48 hours postoperatively)
Pain management
Serial abdominal examinations
Strict fluid and electrolyte balance.
Complications
Early Complications:
Hemorrhage
Hypovolemic shock
Sepsis and intra-abdominal abscess
Fistula formation (entero-cutaneous, entero-enteric)
Anastomotic leak
Re-operation
Pulmonary complications (atelectasis, pneumonia, ARDS)
Acute kidney injury
Multi-organ dysfunction syndrome.
Late Complications:
Adhesions and intestinal obstruction
Incisional hernia
Chronic pain
Post-traumatic stress disorder
Nutritional deficiencies.
Prevention Strategies:
Prompt diagnosis and appropriate surgical intervention
Meticulous surgical technique to control bleeding and achieve adequate organ repair
Judicious use of antibiotics
Early mobilization and pulmonary physiotherapy
Adequate nutritional support
Careful wound closure
Consideration of damage control laparotomy in severely injured patients
Re-exploration for suspected ongoing bleeding or contamination.
Prognosis
Factors Affecting Prognosis:
Hemodynamic status at presentation
Number and severity of injuries
Specific organs injured (e.g., liver, major vascular structures, pancreas)
Presence of shock
Time to definitive surgical treatment
Development of complications such as sepsis or anastomotic leak
Age and comorbidities of the patient.
Outcomes:
Mortality rates vary significantly based on the factors above, ranging from low single digits for minor injuries to over 50% for severe, multiple organ injuries with shock
Morbidity includes prolonged hospitalization, need for multiple surgeries, and long-term functional deficits.
Follow Up:
Postoperative follow-up includes monitoring for wound healing, signs of infection, bowel function, and nutritional status
Patients may require long-term follow-up for complications like adhesions or hernias
Psychological support may also be necessary.
Key Points
Exam Focus:
ABCs of trauma are paramount
Hemodynamic stability dictates management strategy
Midline laparotomy is the workhorse for penetrating abdominal trauma
Damage control surgery principles are essential for unstable patients
Recognize organs at risk for specific injury patterns.
Clinical Pearls:
A negative FAST scan or CT does not exclude injury in a hemodynamically unstable patient
clinical judgment and re-examination are crucial
For gunshot wounds, suspect injury along the bullet's track and potentially beyond
Consider thoracic and pelvic injuries concurrently
Maintain a low threshold for surgical exploration in suspected significant intra-abdominal injury, especially in hemodynamically unstable patients.
Common Mistakes:
Delayed surgical intervention in unstable patients
Incomplete abdominal exploration
Failure to identify and manage hollow viscus injuries
Inadequate fluid or blood resuscitation
Overreliance on imaging in hemodynamically unstable patients
Insufficient antibiotic coverage
Premature closure of abdomen in damage control laparotomy.