Finding What is Wrong*
Moshe Schein
Never let the skin stand between you and the diagnosis.
“In surgery, eyes first and most; fingers next and little; tongue last and least.”
(Humphrey George Murray, 1820–1896)
Not uncommonly, when opening the abdomen, the surgeon knows what to expect inside; the clinical picture and/or ancillary tests direct him to the disease process. In many instances, however, he explores the unknown, led on only by the signs of peritoneal irritation, and assuming that the peritoneal cavity is flooded by blood or pus. Usually, the surgeon speculates about the predicted diagnosis but always remains ready for the unexpected. This is what makes emergency abdomi- nal surgery so exciting and demanding: the ever looming catastrophe and the anxiety about whether or not you are able to tackle it competently.
Abdominal exploration (> Fig. 11.1)
While the specific sequence and extent of abdominal exploration are to be tailored to the clinical circumstances,the two principal stages of any exploration are:
Identification of the specific pathology which prompted the laparotomy
Routine exploration of the peritoneal cavity
Essentially, there is a sharp distinction between a laparotomy for non-traum- atic conditions such as bowel obstruction, inflammation or peritonitis, and laparo- tomy for trauma with intra-abdominal hemorrhage, the later being rarely due to spontaneous, non-traumatic intra-abdominal causes.
So you incise the peritoneum, what now? Your action depends on the urgency of situation (condition of the patient), mechanisms of abdominal pathology (spontaneous versus trauma), and the initial findings (blood, contamination or pus). Whatever you find, follow the main priorities:
Identify and arrest active bleeding
Identify and control continuing contamination
* Asher Hirshberg, MD contributed to this chapter in the 1st edition of the book.
At the same time: do not be distracted by trivia. Do not chase isolated red blood cells or bacteria in a patient who is bleeding to death. For example do not repair minor mesenteric tears in a patient who is busy exsanguinating from a torn inferior vena cava. This is not a joke – surgeons are easily distracted.
Intraperitoneal Blood
The patient may have suffered a blunt or penetrating injury or no injury at all;
in the latter case he is suffering from spontaneous intra-abdominal hemorrhage (abdominal apoplexy), an uncommon entity caused by the etiologies summarized in >Table 11.1.
You may have been expecting the presence of free intra-peritoneal blood from the clinical findings of hypovolemic shock, or the results of the CT, the ultrasound or peritoneal lavage.Your action depends on the magnitude of hemorrhage and the degree of resulting hemodynamic compromise.When the abdomen is full of blood, and the patient unstable, you should act swiftly.
Control the situation:
Enlarge your initial incision generously (avoid liver and bladder)
Lift out the small bowel completely
Suck out blood as fast as possible (always have 2 large suckers ready)
Pack the four quadrants tightly with laparotomy pads Fig. 11.1. “Hey Doc, did you find anything?”
Table 11.1. Causes of spontaneous intra-abdominal hemorrhage (“abdominal apoplexy”) Vascular
Ruptured abdominal aortic aneurysm
Ruptured arterial visceral aneurysm (hepatic, gastroduodenal, splenic, pancreaticoduodenal, renal, gastroepiploic, middle colic, inferior mesenteric, left gastric, ileocolic (may be associated with Ehlers-Danlos syndrome)
Intraperitoneal rupture of varices associated with portal hypertension Spontaneous rupture of the iliac vein
Gynecological
Ruptured ectopic pregnancy
Spontaneous rupture of the pregnant uterus with placenta percreta Postpartum ovarian artery rupture
Spontaneous ovarian hemorrhage (idiopathic, ruptured follicular cyst or corpus luteum, ovarian cancer)
Pancreatitis
Erosion of adjacent vessels involved in the process of severe acute pancreatitis, chronic pancreatitis or pancreatic pseudocyst
Liver
Rupture of benign (typically adenomas) or malignant hepatic tumors Spleen
Spontaneous rupture Adrenal
Spontaneous hemorrhage: normal gland or secondary to tumor Kidney
Spontaneous rupture: normal kidney or secondary to tumor Anti-coagulation
Patients on anticoagulation are prone to spontaneous retroperitoneal or intra-peritoneal bleeding – often prompted by unrecognized minor trauma
Unrecognized or denied trauma
Patient “forgot” the kick to the LUQ, which broke his spleen Miscellaneous
Acute ruptured cholecystitis
Mediolytic arteritis of an omental artery Periarteritis nodosa
Evacuation of massive hemoperitoneum temporarily aggravates hypo- volemia.It releases the tamponade effect and relieves intra-abdominal hypertension
(> Chap. 36), resulting in sudden pooling of blood in the venous circulation. At
this stage,compress the aorta at its diaphragmatic hiatus and let the anesthetist catch up with fluid and blood requirements.
Be patient, do not rush forward; with your fist on the aorta, the abdomen tightly packed, and the patient’s vital organ perfusion improving, you have almost all the time in the world. Do not be tempted to continue with the operation, which can result in successful hemostasis in a dead patient.Relax and plan the next move, remembering that from now on you can afford to lose only a limited amount of blood before the vicious cycle of hypothermia, acidosis, and coagulopathy (“the triangle of death”) will further frustrate efforts to achieve hemostasis.
Primary Survey
Now you are ready to identify and treat the life-threatening injuries.The initial direction of your search will be guided by the causative mechanisms. In penetrating injury the bleeding source should be in the vicinity of the missile or knife tract;
in blunt trauma, bleeding will probably originate from a ruptured solid organ – the liver or spleen – or the pelvic retroperitoneum.
Unpack, suck and re-pack each quadrant consecutively noting where there is blood re-accumulation (active bleeding) or hematoma.Having accurately identified the source (or sources) of bleeding, start definitive hemostasis, the rest of the ab- domen being packed away. Simultaneously, if the situation permits, control con- tamination from injured bowel using clamps, staplers or tapes, or re-packing in desperate situations.
Stay tuned constantly to events behind the blood-brain barrier (BBB)– which is the screen between you and the anesthetists.Wake them up from time to time and ask how the patient is doing.Take this opportunity also to explain how and what you are doing. Communication among members of the medical team in this situation is vital. While you are repairing the iliac vein the patient may be developing a peri- cardial tamponade.
Secondary Survey
Now the exsanguinating lesion is permanently or temporarily controlled and the patient’s hemodynamics have been stabilized. With less adrenaline floating around you can divert your attention to all the rest, and look more precisely around.
With growing experience your abdominal exploration will become more efficient
but never less thorough, as “missed” abdominal injuries continue to be a common source of preventable morbidity.The practicalities of systematic abdominal explora- tion are described below.
Intraperitoneal Contamination or Infection
First you register the offensive fecal smell or fecal-looking fluid that denotes abundance of anaerobic bacteria and usually an infective source in the bowel. Note, however, that neglected infections from any source can be pseudofeculant due to the predominance of anaerobes. When, on opening the peritoneum gas escapes with a hiss, be aware that a viscus has perforated. In the non-trauma situation this usually implies perforated peptic ulcer or sigmoid diverticulitis.Bile-staining of the exudate points to pathology in the biliary tract, gastroduodenum or proximal small bowel.
Dark stout-beer fluid and fat necrosis hints at pancreatic necrosis or infection in the lesser sac.Whatever the nature of contamination or pus, suck and mop it away as soon as possible.
Generally, bile directs you proximally and feces distally, but “simple” pus can come from anywhere. When its source remains elusive, start a systematic search keeping in mind all potential intra and retroperitoneal sources “from the esophagus to the rectum”. Be persistent with your search. We recall a case of spontaneous perforation of the rectum in a young male, twice explored by experienced surgeons who failed to appreciate the minute hole deep in the recto-vesical pouch. It was found during a third operation.
Occasionally, however, the root of contamination or secondary peritonitis is not found. A Gram-stain disclosing a solitary bacterium – as opposed to a few – would support the diagnosis of primary peritonitis, since secondary peritonitis (e.g. secondary to a visceral pathology) is always polymicrobial. More about this
in > Chap. 12.
The Direction and Practicalities of Exploration
This depends on the reason for the laparotomy; here we bring a general plan.
The peritoneal cavity comprises two compartments: the supracolic and the infracolic compartment. The dividing line is the transverse (meso)colon, which in a xipho-pubic midline incision is located approximately in the center of the incision.
It is important to develop and adhere to a fixed routine of abdominal exploration, which will include both compartments. Our preference is to begin with the infra- colic compartment; the transverse colon is retracted upwards, the small bowel eviscerated, and the rectosigmoid identified. Exploration begins with the pelvic
reproductive organs in the female, and then attention is turned to a systematic inspection and palpation of the rectosigmoid, progressing in a retrograde fashion to the left, transverse and then right colon and cecum, including inspection of the mesocolon. The assistant follows the exploration with successive movements of a hand-held retractor to retract the edge of the surgical incision and enable good visualization of whichever abdominal structure is the focus of attention. Explora- tion then proceeds in a retrograde fashion from the ileo-cecal valve to the ligament of Treitz, with special care being taken to inspect both “anterior” and “posterior”
aspects of each loop of bowel as well as its mesentery.
Attention is then turned to the supracolic compartment. The transverse colon is pulled down,and the surgeon inspects and palpates the liver,gallbladder,stomach (including the proper placement of a nasogastric tube), and spleen. Special care should be taken to avoid iatrogenic damage to the spleen caused by pulling hard on the body of the stomach or the greater omentum. A complete abdominal explora- tion also includes entry into the lesser peritoneal sac, which is best undertaken through the gastrocolic omentum. This omentum is usually only a thin avascular membrane on the left side, and this should therefore be the preferred entry route into the lesser sac. Take care to avoid injury to the transverse mesocolon which may be adherent to the gastrocolic omentum. A misdirected surgeon can be convinced that he is entering the lesser sac when in fact he or she is cutting a hole in the trans- verse mesocolon. The gastrocolic omentum is divided between ligatures bringing the body and tail of the pancreas into full view.
Exploration of retroperitoneal structures involves two key mobilization maneuvers, which should be employed whenever access to the retroperitoneum is deemed necessary:
“Kocher’s maneuver”is mobilization of the duodenal loop and the head of the pancreas by incising the thin peritoneal membrane (posterior peritoneum) over- lying the lateral aspect of the duodenum and gradually lifting the duodenum and pancreatic head medially. This maneuver is also the key to surgical exposure of the right kidney and the right adrenal gland. Kocher’s maneuver may be extended further caudad along the “white line” on the lateral aspect of the right colon all the way down to the cecum.This extension allows medial rotation of the right colon and affords good exposure of the right-sided retroperitoneal structures such as the inferior vena cava,iliac vessels and the right ureter.Further extension of this incision angles around the caecum and continues in a supero-medial direction along the line of fusion of the small bowel mesentery to the posterior abdominal wall. Thus it is possible to mobilize and reflect the small bowel upwards, the so-called Catell- Braasch maneuver. This affords optimal exposure of the entire infra-mesocolic retroperitoneum, including the aorta and its infra-renal branches.
The second key mobilization maneuver is called “left-sided Kocher” or “medial visceral rotation” (also called by some the Mattox maneuver although he was not the
first to perform it) and is used especially to gain access to the entire length of the abdominal aorta and to the left-sided retroperitoneal viscera. Depending on the structures to be exposed this maneuver begins either lateral to the spleen (spleno- phrenic and spleno-renal ligament) working caudally or in the “white line” of Toldt lateral to the junction of the descending and sigmoid colon, working upwards. The peritoneum is incised and the viscera, including the left colon, spleen and tail of pancreas are gradually mobilized medially. The left kidney can either be mobilized or left in situ, depending on the surgical target of the exploration.
In cases of spontaneous hemoperitoneum, you’ll have to look for a ruptured aortic, iliac or visceral arterial aneurysm, ectopic pregnancy, bleeding hepatic tumor, spontaneous rupture of an enlarged spleen, or any of the other causes listed
in > Table 11.1. In penetrating trauma you’ll follow the entry-exit tract, taking into
consideration the missile’s energy,velocity and potential to fragment.Wherever the- re is an entry wound in a viscus or blood vessel look for the exit one!The latter may lie concealed on the lesser sac wall of the stomach, the retroperitoneal surface of the duodenum, or the mesenteric edge of the small bowel. It is the blunt abdominal injury, however, that requires the most extensive and less directed search, from the surface of both hemi-diaphragms to the pelvis, from gutter to gutter, on all solid organs, along the whole length of the GI tract, and on the retroperitoneum. (The retroperitoneum selectively, as discussed in > Chap. 35). The exact sequence of exploration is less important than its thoroughness.
Additional Points: Grading the Severity of Injury
Abdominal exploration for trauma ends with a strategic decision about the subsequent steps. Forget at this stage the many available organ injury scales, which are of only academic value; from the operating surgeon’s point of view there are essentially two patterns of visceral damage: “minor trouble” and “major trouble”.
“Minor trouble” involves easily fixable injuries, either because the injured organ is accessible or the surgical solution is straightforward (e.g., splenectomy, suture of mesenteric bleeders,or a colon perforation).There is no immediate danger of exsanguination or loss of surgical control. Under these circumstances you can immediately proceed with definitive repair.
“Major trouble” is when the spontaneous condition or injury is not easily rectified because of complexity or inaccessibility (e.g., a high-grade liver injury, a major retroperitoneal vascular injury in the supracolic compartment,or destruction of the pancreatoduodenal complex).Here the secret of success is to STOP the opera- tion when temporary (usually digital or manual) control of bleeding is achieved.
Take time to optimize the surgical attack on the injured organ. Update all members of the operating and anesthesia teams on the operative plan. Allow your anesthesi-
ologist to use the time to stabilize the patient hemodynamically and to obtain more blood products. (Often you have to think for your anesthetist – don’t assume that he is awake. However, bear in mind that just as you are a “modern” surgeon there are now “modern” anesthetists, and they are an invaluable resource in the management of such patients. Take care not to alienate these excellent practitioners!). Order an autotransfusion device and a full range of vascular and thoracotomy instruments to be brought in. This is also the appropriate time to seek more competent help, and to plan the operative attack, including additional exposure and mobilization.
Such preparations are crucial for the survival of your patient.
Remember: very often the initial exploration of the abdomen in the trauma patient is incomplete, because the patient’s critical condition creates a situation where every minute counts and injuries are simply repaired as they are encountered.
Under these circumstances you must complete the exploration before terminating the procedure.
Finally, first do not harm. This applies everywhere in medicine but is of para- mount importance during abdominal exploration. The injured or infected contents of the peritoneal cavity may be inflamed, swollen, adherent, friable and brittle.
Careless and sloppy manipulation and separation of viscera during exploration commonly induce additional bleeding and may produce additional bowel defects, or enlarge the existing ones. And as usual, new problems translate into additional therapies and morbidity.
This is what makes emergency abdominal surgery so exciting and demanding:
the ever looming catastrophe and the anxiety about whether you are able, or not, to tackle it competently.
