In the past, patients with abdominal injuries routinely underwent exploratory laparotomies for both diagnostic and therapeutic reasons, however with the advent of FAST scans and rapid, high-resolution spiral CT scanners, the added diagnostic benefit of the “ex-lap” has diminished significantly. Furthermore, advances in interventional radiology / angiography have made it possible to treat solid organ hemorrhages without the need for a laparotomy, further reducing the need for abdominal incision in the trauma setting.
When surgery is indicated, many surgeons operate under the principle of “damage control” as explained by Rotondo et al., who stated that “Physiologic derangements such as dilutional coagulopathy, hypothermia, and acidosis often preclude completion of the procedure. Damage control, defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the ICU and subsequent definitive re-exploration…” Rotondo’s group conducted a small (n = 46), retrospective study comparing definitive surgery to damage control in patients with penetrating abdominal injuries requiring laparotomy transfusion of more than 10 units PRBCs, finding no significant differences in any outcome measured. (1)
Focus should be on adequate IV access, availability of a rapid infusion system, and obtaining continuous pressure monitoring (and availability of rapid lab draws, i.e. arterial catheterization). Cell savers are often not possible because the peritoneum is often contaminated in these patients. Keep in mind that many of these patients will be re-operated on in 24-48 hours, and that subsequent procedures can be complicated by adhesions and scarring.
M F Rotondo, C W Schwab, M D McGonigal, G R Phillips, T M Fruchterman, D R Kauder, B A Latenser, P A Angood
‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury.
J Trauma: 1993, 35(3);375-82; discussion 382-3
[PubMed:8371295] [WorldCat.org] (P p)