Abstract
- The anterior abdominal wall has four muscles: The external oblique, the internal oblique, the transversalis, and the rectus muscles. The aponeuroses of the first three muscles form the rectus sheath, which encloses the rectus abdominis muscle.
- The linea alba is a midline aponeurosis that runs from the xiphoid process to the pubic symphysis and separates the left and right rectus abdominis muscles. It is widest just above the umbilicus, facilitating entry into the peritoneal cavity.
- For vascular trauma purposes, the retroperitoneum is conventionally divided into four anatomic areas:
- Zone 1: Extends from the aortic hiatus to the sacral promontory. This zone is subdivided into the supramesocolic and inframesocolic areas. The supramesocolic area contains the suprarenal aorta and its major branches (celiac axis, superior mesenteric artery (SMA), and renal arteries), the upper inferior vena cava (IVC) with its major branches, and the superior mesenteric vein (SMV). The inframesocolic area contains the infrarenal aorta and IVC.
- Zone 2: Includes the kidneys, paracolic gutters, renal vessels, and ureters.
- Zone 3: Includes the pelvic retroperitoneum, containing the iliac vessels and ureters.
- Zone 4: Includes the perihepatic area, with the hepatic artery, the portal vein, the retrohepatic IVC, and hepatic veins.
- Zone 1: Extends from the aortic hiatus to the sacral promontory. This zone is subdivided into the supramesocolic and inframesocolic areas. The supramesocolic area contains the suprarenal aorta and its major branches (celiac axis, superior mesenteric artery (SMA), and renal arteries), the upper inferior vena cava (IVC) with its major branches, and the superior mesenteric vein (SMV). The inframesocolic area contains the infrarenal aorta and IVC.
Surgical Anatomy
The anterior abdominal wall has four muscles: The external oblique, the internal oblique, the transversalis, and the rectus muscles. The aponeuroses of the first three muscles form the rectus sheath, which encloses the rectus abdominis muscle.
The linea alba is a midline aponeurosis that runs from the xiphoid process to the pubic symphysis and separates the left and right rectus abdominis muscles. It is widest just above the umbilicus, facilitating entry into the peritoneal cavity.
For vascular trauma purposes, the retroperitoneum is conventionally divided into four anatomic areas:
Zone 1: Extends from the aortic hiatus to the sacral promontory. This zone is subdivided into the supramesocolic and inframesocolic areas. The supramesocolic area contains the suprarenal aorta and its major branches (celiac axis, superior mesenteric artery (SMA), and renal arteries), the upper inferior vena cava (IVC) with its major branches, and the superior mesenteric vein (SMV). The inframesocolic area contains the infrarenal aorta and IVC.
Zone 2: Includes the kidneys, paracolic gutters, renal vessels, and ureters.
Zone 3: Includes the pelvic retroperitoneum, containing the iliac vessels and ureters.
Zone 4: Includes the perihepatic area, with the hepatic artery, the portal vein, the retrohepatic IVC, and hepatic veins.
General Technical Principles
A laparotomy for bleeding is different from a laparotomy for peritonitis.
The top priority of the surgeon is to stop the bleeding. This should be followed by a methodical exploration of all structures to identify and repair other non-life-threatening injuries.
In appropriate cases, consider early damage control before major physiological deterioration (coagulopathy, hypothermia, acidosis) occurs. In determining the need for damage control, the surgeon needs to take into account the nature of the injury, associated injuries, the physiological condition of the patient, the hospital capabilities, the skillset of the surgeon, and time required to achieve definitive repair.
Removal versus repair for organs, such as the spleen and kidney, should be determined by the injury severity and physiologic condition of the patient.
If damage control packing does not stop the bleeding, do not terminate the operation. Re-explore, identify, and control any surgical bleeding.
In damage-control procedures, the abdomen should always be left open, using temporary closure techniques. This prevents the development of intra-abdominal hypertension or abdominal compartment syndrome and allows immediate repeat exploration if necessary.
Positioning of Patient and Skin Preparation
The patient should be placed in the supine position with the arms abducted to 90° to allow anesthesia to obtain access for resuscitation.
If there is concern for rectal or anal canal injury, the patient may be placed in lithotomy position.
The bed rails should be free and exposed for fixed surgical retractor placement bilaterally.
The patient should undergo a standard trauma preparation from chin to knees and laterally to the bed. Inclusion of the groins in the field is important because of the possibility of the need of saphenous vein graft.
Figure 22.2 Position and skin preparation for trauma laparotomy. The patient should be prepped from chin to knees and laterally to the bed (posterior axillary lines).
Incisions
A full midline laparotomy is the standard incision in trauma. The extent of the incision is determined by the suspected location of injury and the condition of the patient. The incision should be long enough to provide comfortable exposure and allow a complete exploration of the abdomen. A xiphoid to pubic symphysis incision should be considered in hemodynamically unstable patients with blunt trauma, as well as penetrating trauma and unknown missile trajectories. The concept of routine xiphoid to pubic symphysis incision in all trauma laparotomies is not advisable.
In a hypotensive patient, the abdomen should be entered quickly, without wasting time for local hemostasis. The skin, subcutaneous tissue, and the linea alba are incised sharply. The best place to incise the linea alba is 2–3 cm above the umbilicus, where the aponeurosis is at its widest part and there is a reduced risk of entering the rectus sheath. The preperitoneal fat is then swept away and the peritoneum is identified and entered. A finger can be used to enter the peritoneal cavity just superior to the umbilicus at the thinnest point.
