A sensitive way to evaluate for intra-abdominal injury in the trauma patient
In Blunt Trauma
Unexplained hypotension
Concern for injury but no obvious indication for laparotomy and serial abdominal examinations are not practical (i.e., unconscious or under anesthesia)
Equivocal focused abdominal sonography for trauma (FAST) examination and concern for an intra-abdominal injury
Patient unsuitable for computed tomography (CT) in whom there is concern for intra-abdominal injury
Concern for mesenteric or hollow viscous injury not seen on CT
In Penetrating Trauma
Anterior abdominal stab wound and evidence of fascial penetration in the stable patient with no obvious indication for laparotomy
To evaluate for hollow organ or diaphragmatic injury in the stable patient
CONTRAINDICATIONS
Absolute Contraindications
Indication for an emergent laparotomy
Relative Contraindications
Prior abdominal surgery
Second or third trimester of pregnancy—consider open technique with supraumbilical approach
Morbid obesity
Significant ascites
Coagulopathy
General Basic Steps
Prepare patient
Analgesia
Technique
Open
Incision
Dissection
Incise fascia, then peritoneum
Place dialysis catheter
Closed
Needle into abdomen
Thread guidewire
Small skin incision
Thread dialysis catheter
Aspirate
Lavage/Drainage of fluid
Analysis of fluid
LANDMARKS
The incision should be made in the midline, one-third of the way between the umbilicus and pubic symphysis. In the pregnant patient or the patient with a pelvic fracture, the incision should be made in the midline, just above the umbilicus (FIGURE 16.1).
SUPPLIES
1% Lidocaine with epinephrine, 20 mL with 25-gauge needle, 10-mL syringe
Sterile towels or drapes, sterile gown and gloves, mask, and eye protection
Povidone–iodine (Betadine) solution or chlorhexidine
11-Blade scalpel
Syringe and needle (for closed technique)
Flexible guidewire (for closed technique)
Two clamps and two retractors (for open technique)
Peritoneal catheter
1 L warm saline for infusion (for lavage)
Tubing to let lavage fluid drain
Suture (for open technique)
TECHNIQUE
Preparation
Place a Foley catheter (unless contraindicated)
Place a nasogastric tube (unless contraindicated) to suction to decompress the stomach
Gather all instruments and sterile gown/gloves
Sterilize the abdomen from costal margin to pubis and from flank to flank with povidone–iodine solution (Betadine) or chlorhexidine
Drape the area with sterile towels or drapes