t'-

I||P
IIITART& GRA]I||TIRAUTIIA
SURGTRY
IIE

AsherHirshbergMD
&
KennethL. Mattox MD

Edited by Maty K. Allen

Illustrated by Scott Weldon
 TOPKNIFE
TheAd a C ofl ofTrolmo slrgery

lJmPub shingLtd, CastleHillBarns,Harley,Nr Shrewsbury,

SY5 6LX, UK.
Telr+44 (0)1952510061iFax:+44 (0)1952510192
E-mai nikki@lfnrpublishing.com;
Web s ie: www.ifmpublishing.com

Ediior: lMaryK Allen

Designand ayout: Nikk Bramhll
Coverdesign:
lllstrationsby ScotiWeldon,CopyrighiO BayorCollegeof Medcine2005

CopyightO January2005,AsherH rshbergMD & KennethL MattoxMD

ReprntedApri 2005, October 2006

lsBN 1 90337822 2

Apad ironr any fair dea ing for the purposesof researchor privatestudy,
or crtcsrn or review,as permlttedunderthe Copyright,Designsand
PaientsAcl 1988,this publcatonrnaynot be reproduced, stored n a
retneva sysiem or irarsmitted n any forrn or by any means,eectronic,
digiial,mechanica,photocopyng,recordingor othelwise,witholt the
prior writtenpermisson of the publisher.

NOTICE
Neiherthe authors,norlhe pubisher,nor anyotherpartywho has been
invoved in lhe preparaiionor publication of this work can accept
responsibiltyfor any injuryor damageto personsor propertyoccasioned
throughihe mp ementationol any ideasor use of any productdescribed
herein,Neiihercan they accepl any responsbriiy for errors,or.iss ons or
msrepresentatrons, howsoever caused,

Whilst everycare is takenby the authors,the ed tors and the p!b isherto
ensure that all informatiof and data in ths book are as accurateas
possibe ai ihe time of goingio press,il is recommendedthai readersseek
independeni verJcaton of adviceon drugor oihefproductusage,surgical
racl_n
qJes.r d c irKa p.ocess6c pr or to r'rei.Jsa.
 E
!
Contents

pqge

I
Introduction
What this Book is all About

SEcrloN I - Tools oF THETRADE

Chapterl
r The 3-D TraumaSurgeon

19
Chapter 2
Stop That Bleeding!

ct'upte'e 35
i
I Youi Vascular Toolkit
I
i SEcrIoN II - THE ABDoMEN

Chapter 4
53
The Cxash Lapalotomy

Chapter 5
7L
Fixing Tubes: The Hollow Organs

Chapter 6
The Injured Liver Ninja Masier

Chapter 7
99
The ' Take-outable" Solid Organs
 TOPKNIFE
TheAr1& Croft of TroumoSuroerv

pase

Chapter8 115
TheWoundedSurgicalSoul

Chapter9 131
Big Red & Big Blue:Abdominal VascularTmuma

SEcrroN III - THE CHESr

Chapter10 147
Dorble Jeopardy:ThoracoabdominalInjudes

Chaptff 11 157
The No-nonsense Trauma Thoracotomy

Chapter 12 17L
The Chesr Inside and Out

Chapter 13 181
Thoracic Vascular Tmuma for the General Surgeon

SEcrIoN IV - THE NECK AND ExrREMrrrEs

Chapter 14
't99
The Neck: SaJadin Tiger Counhy

Chapter lS 215
Peripheral Vascular Trauma Made Simpl€

Epilogue 233
TheJoy of TraumaSuigery
 Contributors

Authors
in the Depariment o{ Surgery'
AsherHirshbergMD FACS,is Professor
of Emergency
iut" o.*n",*" college of N/edicineand Director
in Bfooklyn'NewYork
i"'""rtu!'Srrg"ry XingsCountyHospiialCenier
"t
KennethL. ManoxN4DFACS,is Prolessor andViceChairof theMichael
and
i. o"ir*t Deparir.entof surgery,Baylorcollegeo{ Medicine'
Hospltal'
Cn[i si"olin*t of Surgeryat the Ben Taub General
"t

lllustletot

Scott WeldonN,4A,is Supervisor Medicallllusiratorin the Divisiono{

surgery of the MichaelE DeBakeyDepartmentol
Cardiothoracic
Houston'
BaylorCollegeof lvledicine,
Surgery, Texas'

Editot

MaryK. AllenBA, is Administrative in ihe MichaelE DeBakey

Associate
of
andAdministrator
o"p"ri-"nt ot srrg.ry, BaylorCollegeo{ N4edicine'
Houslon'Texas
the SurgeryDivisio;al ihe BenTaubGeneralHospital'
 To our residents-
past,presentandfuture
 Introduction
What this Book is all About

Whenyou hatteto shoot- shoot'dofl't talk

- I1i Wallach (Tuco)
in: TheGaotl' the Badand lhe U+l! ' 19136

Sooneror later,I haPPens'

your first night on call at a

You are a young aitendingsurgeondoing
ur"u tt""t" ol. in a communityhospltalfacing a bad
""*o " "rig"on a miliiafysurgeon
traLr'ma casealoneand wiihoutbackup Pefhapsyouare
or later'you Jindyourseli
witn a forwarO or fietO SurgicalTeam sooner
patienirapidlydyrng
in tt e operating-om 1OR);ith a massivelybleeding

LooD" o{ bowe are

YoJ o|.icklvopen ll^F beJyand blood gushesout
i-''" p.a a"rr btooda'd c'oLsHecticactiviysJrroJrdsvoL
"f more lines while ihe
as the aneslhesiologyieam struggEs ro open
"*^.'ln
rrav5 YoLdon\ needIo
;;";",'"; ,.." rursJ" rapidlvoeprov'nsrLmeri
rhe
,J*l, in" nrmbei, or rtte -ontor to lealireIl"aIlhrs's
"n-"n to acquireare suddenly
Moment.The skillsthat you haveworkedso hard
pui to a very bruialtest Can you meetthe challenge?

room (ER)
These cases almost invafiablyroll ihroughthe emergency
aoor" *h"n vo, t""t yo, are not at yourbest'notYouaretired and tunningon
u"i"ti"" Your sc,ub nu'"e is very experienced'The
"rrlii".t
i"i.f"g afe doing lheir besi by pushing bolus after bolus of a
"t" o'I
""""tf
;;;;;;" iror'ooic-asenl rne crrcu'|arilsnJ se d s'ppeared
";"" lavorile
vascJlar clamo
in" r"lrt *t""" t"" -'"utes igoin searcr'o'your
we can assureyou' it never is
Yes,this is deflnltelynot a good iime, bul
chaos around yo!' the
Tie audlblebleedingin tho belly,the controlled
and the clLrelessassistantacross the
iii"n*n *a ,'ght" ii your head,
 TOPKNIFE
TheAd & Croft of TroumoSurgery

operalingtab e are all pad of real-lifetraumasurgery.Oh, and by the way,

haveyou noticedthe anorexicchap in the black robe and hood,standing
in the corner of the OR, holdingthis big scythe,and patientywailirg for
you io make lusl one mistake?He, too, s an iniegral part of lrauma
surgery.

Traurnasurgeryis an art ihat combinesdecision-making wth technica

and leadershlpskllls.The purposeof this book is io help you take a badly
woundedpatientto the OR, organze yourselfand your team, do battle
with some viciousinjuries,and come out wiih a live patieniand the best
possibleresult.The siardard surgicalatlasmayshow you whal to do wrth
youf hands bul not how to ihink, plan, and improvise.This book is
different.Here you wlllfind practrcaladviceon how to use your head as
wel as your handswhen you are operatng on a cfashingtraumapatient.

Who shouldreadthis book?Afe you a resldenior registrarin the senor

years of slrgical traning? A generalsurgeon iniefestedln trauma?A
felow ln traurnaand crrtcal care? lf you are, we wrote this book primarily
wilhyou in m nd.

lf you are cufrentlyin lfaining,you must be aware oI ihe strongforces

dramaiicallyfeducing your operative trauma experience.lJrban
penetraiingiraumais dec ining,non'operatrve r.anagementis on the rise,
and surgica trainng is undergoinga noisy revouUon.Whle this book
cannotsubstitlte for gelting your clogs wet in a real OR, i can opt r.ize
ihe educationavalueof everyAaumaoperationyou do becauseyou wii

lvlanyoperativeencounterswith bad inluriesiake place in austere

cifcumsiances,The rura surgeondoingan occasonalmajoryaumacase
alone,the miitary surgeonin the f eld, and ihe disasief reliefieam on a
humanitarianmission are examplesof irauma surgery wilh extremely
I mitedresources.Tacklinga high-gradeliveri.jury n a largeiraumacenter
is bad enough.Do ng it n the only OR o{ a 20-bedhospila iakes tons of
courageand resourceJu ness. li you afe ore of ihose surgeons,you are
probablymore nteresiedin slmpletechncal solulionsthat work, raiher
than complex maneuversthat you wonii use aryway, Most operatve
problernsin traumahavemorethan one effeciiveanswer,and the trick ls
 lntroductlon
w,o ih BoorB or ""., E

lo tailora simple,feasiblesoluiionto your speclficcircunrstances.

In this
book,we show you how to do jusi ihat.

Ths brings us to damage control, the biggesi buzzwordin trauma

surgeryin the lasi decade.You rnaywonder why you don't see a chapter
on damagecontrolin the book.The answerrs simple.Damagecontrolhas
becomesuch a centfaltheme in traumasurgerythal it no longermakes
senselo confineit to a singlechapler Instead,detaied descriptionsof
damagecontroloptionsandlechnlquesare partoJeverychapter.Thinking
of ihis book as a comprehensiveguideio damagecontrolwould noi be a

Why Top Knife?Top Gun is the popularname of the Naval Fighters

WeaponsSchool.The r missionis io trainthe very besi fighterpilotsfor
ihe US Navy.We calledour baok Tap Knife)n recognitionof the many
simrlaritiesbetween trauma surgeonsand frghter pilots: clear thifking
underpressure,respondingeffectivelylo rapidlychangingstuatons, and
a ong and arduous training process. Just like aerial combai, iralma
surgeryis, f rst and foremost,a disciplne. You cannotbecomea frghier
piot or traumasurgeonwithouta lot of hard work and willingnessto face

The book beginsand ends in lhe OR. lf you are lookingfor information
on careof ihe njuredpatientbeJoreor afterihe operation,looke sewhere.
We also assumethat yo! are famillarwith generalsurgicalprincp es and
lechniques.lf you seek nstruclionon how to reseciandloin bowelor how
to do a standardvascularanastomosis, you w ll not find lt here.However,
if you wish io learnhow io do a no-nonsense crash laparoiomy, deal with
a bleedng Lung,or repairan injuredpoplitealariefy,read on.

The f rst seciionof the book, Toalsof the Trade,presentsprinclplesof

irauma surgerythat cll across injurytypes and afatomicalareas. Our
focls s not so muchon how you shouldbe sewing,but ratheron how you
should be thinkingand reactlng.These skillsare rarey if ever talght ln
surgicalirainlng.lf anyoneevershowedyo! how io developan alternative
planwhllestrugglingwilh a bleedingsubcavlanarteryor to pay aiteniion
to whatthe circulatingnurse s do ng whileyou are manualycompressng
a shatteredliver,consideryourselfvery fortunaie.IVostsurgicalresidenls
 TheArt & Croli of TroumoSurgery
ToP KNIFE

just inluiiively piok up those skills

and regislrars are expecled to
do'
somewherealongihe way Manynever

as a conlact sport Here

The resi of the book is abouttraumasurgery
injuriesAn impodantlhemeis how
*"'"i".* t"" n",r a o""lwith speci{ic in
it',ino" go an aspect of traumasurgeryseldomaddressed
"rong, pitrallsbecauserecosnizinsthem is an
:i,"L;J "un;J; t;";.onaiize
essentialpart of learning10operale
traumasurgeryvary among
We acknowledgethat the ari and craft o{
lo find somedifferencesin the approaches
orlrLlplFsare
orob'e-sbetweenIneauLnorsTl"eunoerlyinq
"";""";.';;"'il;",'prised
r^,i.'^r^rrue
d qere'.r'wl'ere such vaf:alio'rs
;":;;; il ''"
""r-n'q,"" "o'"t'""s
one sizefits all'
exlt, we havepointedthem oLll No

good fortuneto parinerwiih Scott

In developingthis book we had ihe
w"faon, giftedyoungmedicalillustraior'The iranslatron
"n'""ti"otain"tily nto qrapnrcartot- 's alwavsa t '(v
.i .*"t",,a"".
"no.o*"ot* we we'e able lo
ff'..1't to Scoii " taent and sLperbi,rlurtror'
"""i."""t. tni" author_artist parinershipas a single voice that seamlessly
""fr"""
interweaves text and an.

ever worked wth did

lvlarvAlFn, t\e most larenlpdFdtor we l^ave
bearh ilLo sl'aoeunt.lst'e
,oln" ,'uoi"o ruro",y ot lne ipn ano mercrlessly
wouldhavebeen
g";ii!", tiglt. Wih'*, t'er remarkablee{forts'this book
much longer_and considerablyless readaEle'
in this proieci {rom
Nikki Bramhlll,our publisher,was a lull padicipanl
bougll 'nto our idea to
rhe embrvolic sLages10 lhe ii'rar prodLct She
*""1 op"ral'vebookor rraLmasurgery andwo'led
*rit" 'jtt.";l:""
"" ;;"t happen Her infeciious
;';;;" step o{ the wav io make it
evidenlon every page'
enihusiasm,h;rd work' and superbeye are
- cutting
And now, ii s iime to stop talking and start
 Chapter 1
The 3-D Trauma Surgeon

An erpett is a man who has madeall

possiblemistakesi a oerynaftowfielil
- Neils Bohr

The flrst thing you noticeon enleringlhe peritonealcavily is bleeding

from a arge nastyholejn the rightlobe of ihe llver Sirangey enough,you
were in exacty lhe same siiuaiiona week ago You don'i even haveto
glance at the monitorlo know the syslolic pressureis go ng to be 60
Rememberinglast week's case, you rapidly pack ihe liver to stop the
beeding.Howeler,thisiime the injuredvet continues io beed through
the packs. lt was supposedto stop. lt did last week. What's wrong?
Whai's different?You do a Pringlemaneuver,but it doesnt help much-
The rietalllc voice of the anesthesiologistalerts you that the patreni's
systoicpressurels now unobtainable. He s dying What s gong on?
What do you do now?

You rerialn surprisinglycalm for a sutgica residentwith ony three of

four yearsof training.The reasonis simple:you know exactlywhai comes
nexi.Soonthe lightsn the SurgicalVrtuaLRealityLabwillbe turnedon
and ihe simllationwil pause.Using a revolvinghoogram of lhe injuted
Liverand retrohepaticveins,your instructorwil explainwhat went wrong
and why. This dry clogs' approach to teachlng surgety ls rapidly
becominga majorpart of surgicalitaining.A simulatorcan helPyo! learn
10operale,yel somerhrng l.r_dame'lrais aissi'g

When you work on a simulator,operaiein a largeanimallab,or work in

the OR with a good ieachingassistant,you learnihe taclica dimensionof
the operaiion.You learn to select from severaltechnical optlons ard
executeyourchoiceln specificoperativecircumstances- You spendmosl
of your surgical training focused on operativetactcs in electiveand
emergencyprocedures.Only when you begin operatlngon your own do
you become aware of the olher two dirnensionsof every operation:
sirategyand team leadershiP.
 Slrgerv
TOPKNIFElhe Arl & Crofi ol lroumo

The shategicdimension
oJ an oPeraiion is ihe
broad considerationol
goals, means, and
alternatives. When You
operale with a teachrng
assistant,Your teacher
usually handles ihe
strategicdimensionlor
you. While You are
absorbedin mobllizing the
spl€nlc tlexure, Your
ieacher is already
weighingthe optionsof a
rapid damage control
laparotomy againsta time-
on your own' tne
consuminodefinrtiverepair.when you are working
"ait"""io"
suddenlyfalls on your shouldefs You can no longer
'Big
",r.*i" alsoconsiderthe
io"r"""*"tr"iu"tv on d," fole; ln the colon,but must

Being a
The ihird dimensionof every operationls team leadetship
the OR ieam members are
surqeonmeansmakingsurethat ihe etforiso{
assume yoLlr
coordinatedand {ocused on ihe same goals You cannoi
because he or she is smari and
t""t' lno*" tt'"t to do nextlust
"irui your pLan Similarly'the
experienced.You must clearly communicale
percepiionand cannot guess
anesthesiologistdoes not haveextrasensory
dunnga
yourplanuniessyou shareit- Mishandling team dlmension
ihe
you can make
iuuma op"rationis one of the worsi mlstakes

train yourselfto
To operateeffectivelyon woundedpaiients'you musi
in and out ot the
be a 3-dimensionalsurgeon who consianilyzooms
nronlioring Progress ano
lactical, strategic, and team dirnensions'
reassessingoptionsin each
 I The 3 D Troumoslrgeon

in motion
Putting brain in gear before knife
oe{ore yo!' make the 'ncslon
Srraleqic lnrnk;ngis essentialeven
oJ,sLrse'[
no'e',
;;^d;: ;,'";"-pi",he brack l;'fitiii,"J:.;"f:
obrisatorv,os;s
#,'-Jl-il:iiJ"" r,san
::i:'",'::il:::,H""6J ano preoa-edbut
p..,entis'novFd oosirioned
[1;;;;::;;;;';r'""
nothingis done 10stop inlernalbleedrng
holeiniewalat ihe scrub srnK'
l{ vou chooseto spendmostof the black
*" i'"" * -*t;;an fingernalls,but when you enterthe oR vou will
Ihp wrong
""i
i; ;;;;;';;"""'tv oosiiionedLl'escrub nLrseprepo'ns
battle
i,"rl. ,t'" on,"". in disartayYouaraywelr haverosl'ne
""1 "nort sravwrthvouroatienl unl" the'asl
#;;;;;;;"..; ro avoidtl''|s
p'eoaratiols
o"i"ii'" .iit*t -a *e InP olackhore e'ective
lor

the OR ieam know which

ls the patient positionedproperly?Does Doesrhe
;J ; ;;;;" ,ni *n''r''""t"'".' to deorov?
"""]"1"" -"".
"ers
You ca'not address these
;;;;"'. need he p wilr^ rres?
vouaresurethat
anas"rubonlvwhen
ir!ii'.#r",n ir''"""',u "inkGo
everyihingis set uP ano reaoy'

on scrubbing Everysecond
lf the patieniis in shock,don't waste.time
j*, g" u go"n und gloves'grab a knife'and rapidlydive intothe
"orni".
chesi or abdomen.

shock
Sterilityis a luxuryin severehemorrhagic

The way You Posiiionthe

patientand definethe operatlve
lield are otherindicatorcof }/our
sirategicvision.AlwaysPfepare
lof a worst_casescenario' In
iorso irauma, this typically
involvesaccesslo bothsideso{
the diaphragm and to the
grolns, Your worst_case
operativefield extendsfromihe
chin to above the knees'
 IOP KNIFE
lhe Art & Croli of TroumoSuroerv

between the posterior axtllarylines. Abduct both arms to allow the

anesthesrology
team full accessto the upperextremities.

For isolatedextremitytrauma,includethe entire niuredextreriilyin the

fieldto facilitaternanipulation,
and preparean uniniuredlowerextremity{or
saphenousvein harvesting.For a neck exploration,pfepare ihe entire
chest,sincethe uoDermediastinumis a coniinuationof ihe neck.

Alwaysprepfor a worst-casescenario

ABC of tactical thinking

Traif yourselfto ihink of everyoperatlonas a sequenceof well-defned

steps,but menrorizing the steps is not enough.You must ga n insightinto
the procedureby earningthe key maneuverand the piiJallin everystep.

A key maneuveris the single most importanttechnical act in an

operativestep.The keymaneuverin mobjlizingan injuredspleenis incisng
the splenorenallgament and entering the correct plane beiwean ihe
spleenand the krdney.Often,a key maneuveris identlfyinga gatekeeper,
a siructureihat servesas a guideto dissectionor opensthe cofrectiiss!e
plane.Thegalekeeperofthe carotidarteryin the neckis the commonfacia
vein. ldentfyingand dviding it is the key maneuver.When mobi zing the
hepaticflexureof the colon,the key maneuveris findingihe planebetween
the rlghtsideof the transversecolonand the duodenum.

A p/tfal/is a majortrapthat awaltsyou in everyoperativestep.Choosng

an incorrectihoracoiomyincisionor perfoming it ai ihe wfong inlercostal
space is a majorpitfalj.Fail!re to obtainproximalcontrolbe{oreplunging
into a containedhemaiomais anotherclassc trap,

Famliarity with both the key r.aneuver and classic pitfall of every
operatve step s the differencebetweenthe trauma pro andthe wannabe.
Knowingthe keymaneuvers andpitfallsofa procedureallowsyouto pei{orm
the procedurelndependently and, with experience,teachlt io others.

Knowthe keymaneuverand pitfallin everyoperativestep

 t rhe 3-Drro,rmosurseonI

A common tactical dilemma

jlilH;"i""ji;ft
:;:1::ilil1',::ilT ::::"H;Fti
"l:";f 1['ili::^-H]
Tiit"i,l,"?:Jl[:":'ff
?:r,ff
ily:Jt"f
iK,f -t""
ut it willwo* thistimeWecantellyou
maybe
oJ"""i t-i
ii::t'*"ll];rl:::lxH"lff
:il;:*[:lmig
"naini
il"'
:;:lJ
Getused thatn,Ihe
iolr"eided nt ::"",liJli"i"TJJ::1"::":::j
"*"'"-'";'ill'liJl"i,liiil;'i] Ll'l"""'";'|t 'ai'|
-re'rrect no'l
ve'|v
i€ke:t as a oersondl
*n"" a maneLver ooesrt wori don
failure.Pauseand consideryouroptlons'
"."*i"'',

First,reconsidefthe need{orthe
lailed ac1. ls it reallynecessary?
Doesihe bleederrequirea sulure? getreaf
Perhapsit will stop wlth iemporary
pressureand Patience'

AnotheroPtionis to retreatand
.f"
ca
gei help lt You are iortunate
enough to have backup' use lI'
o
Someonemore experiencedoiten
has a betterchanceof solvingthe
t.
problem,Recognizing the needlor
irelpand askingfor ii (whether you
or
are a resident seasoned trauma
surgeon), is a sign of good
ludgmenl

iryou
what compreierv
are *i"J,?:;J;til;,:::lilT:
":1111:Y:
upwirh
l'"" "stcome one
l::'[f]''T#'.""''fl5'$li]:"i"."iJ::1ff
ihai will.

,i:ili,tii,'i5;Jlliiiill
,'"Hl"i::"i:Xff T:['""5i
ll'iil"Jff
 TOPKNIFE
TheAri a Crofiof TroumoSurgery

envrronment: lletter exposure,an improvedangle,a longerneedledrrver,

a bigger needle,or a better asslstant.Such a taciical change
improves
your chance to succeed in ihe next aitempi. tdentjcatrepetitionof an
unsuccessful iechnicalact is a nristakebecauseii almostalwaysfails.Thrs
is lhe very deflnitionof flailingand exactlywhai you must avoid.

Rememberthesefour optionsfor dealingwlthtechnicalfailure.Theyare

youriicketsoui offrustraUngand dangeroussituations.Effectjvesurqeofs
don I takelech'r,cattalLreas a persora.nsrtt.Tt-ey.apdly reasse;sthe
siluationand come up with an alternativesolltion.

Avoidflailing;
learnto dealwithtechnicalfailufe

Tactical flexibility

Regafdlessofyour experience, you willfi/rdyourseifin sttuatrons where

your inventoryof slandardtechniquessimplywill not solvethe problem,
forcingyou to figure out a new solution.Tactlcalflexibilityjs the abilityto
devisenew solutionsto unusualoperativesituations.lt is an acquiredsklll
that you can developby learningto thinkoutsideihe box.

When facing an unfamiliarproblenr,ask yourselJthe following

a Havelencouniered a srmilar
sttuation
in anothercontext? ln electve
surgery?In anotherinjuredorgan or anatomicalregion?
a Can I modifyor adapi a standardtechniqueto the situation?
a How aboutsolvingpart of the problem?
a Can I leavethe probem unsolved{or a whileand come back later?
a Whai is lhe mininralaccepiableoptionto deatwtththe probtem?Witl
drainingthe niury(andcreaiinga conifolledfisrua) be good enough?
Can I hgatethe vessellnsteadof repairifg it?

In a complex
situation,
alwaysstrlveto simpllfy
theproblem.
Assessihe
iniufresanddecidewhichinjuredorgansmustbe fixedandwhichcanbe
rapidlyremoved(or fesected)and, thus,etiminaied fromthe equation.
 1 The3-DTroumosureeon I

lrnes
Makeyour reconstructions as simpleas possible.The fewer suture
solutionsworKi compLex
yoLrrnake,the better.ln traumasurgery'simple
solulionsoften backfireon You

Simplitycomplextacticalsituations

The key stratedcdecision

sequenceof reproducible
Everytraumaoperationfollowsa generic
andspillage
the injuredcavity'controlbleeding
o"-0".i", g;t
;#; t;;;;;,y
""""*,o
'"""u,.", then exploreihe cavitvto definethe
"ni

K" \..t11- a
//
//,// "*'
t! \
+\9 ot;*a
"
"
/7/
Acc€$ and
Expo.ur€
F'i'
Bleedlng
TempoEry
conlrol
\
ErploEtion
!
dh
ope-aiion ll'e cro'ce
Now voJ lace tl'e kev strategicoecison ol tl'e
rcpai mears
o"*""" a"ti'ni"" 'epai' ana Ja-ag" control Dernd^e
and {omal closureoJ ihe cavity'
Lection or reparrof the injuredorgans
'Fti',i and
measures
control
bailoutu"ingtemporary
l-""i"* ""ri,[,."i.",^pij
U""rr" ol Ihe cav;ty. will' a plannedrelur' 'ater under mo'F
ju"r {
,,;;;;"'";;"";""-. vo, -at'" it' d""'s'on vFrvearv Don\ 1d
" pai|enl rs crasnlng
yoursel{abruptlybailingout in mid'operation becauseihe

Considerfouf key Jaciors:

How do You choosethe operativeprofile?
and
physiology' system
iniurvoaiter;,rauma br.rrden,

a Whatis ihe injuryPattern?

Forexample, liverinlury'onceyou recognizethe need
in a high-grade
 TOPKNIFE]he Ad & Croit of TroumoSurgery

for packng, damagecontrolis your only choice.Simiarly,the

combinationof a major abdominalvascuJarinjury and intesiinal
perforalionsusuallyrequiresa rapd bailout, becauseby the time you
finish dealingwith the injurediliac artery,the patientwil be n no
conditionto undergobowelresectionand anasiomosis,
a What is the paiient'soverallifaumaburden?
Look nto the njuredbellythow manyorgansdo you needto lix? How
r.uch work is involved?What aboutthechest?Any pressng concerns
in the Imbs? The pateft may needtwo hoursof reconstructive work,
blt with a headinjuryand a diaied righi p!p I, you don'i havethe iime.
The overaltraumaburde. oi a pailent s a combinationof the njuries,
iheir relativeurgency,and the amountof work (andtime) requiredto
deal wiih ihem. Investingpreciousirme in definitiverepairof nonl/fe
ihreaieningabdominalinjuriesn the presenceoJ big uncenaintiesin
ihe head,chesi,or neck is a very bad move.
a Whai is the patients physiology?
The numbersyou see on ihe anesthesiologist s monitorare noi very
he piul becauseyou are not interestedin a snapsholof ihe patient's
blood pressure or oxygen saturation.You are ifierested in ihe
physiologcalimpactof ihe njuryovertime.The instanianeous numbers
yousee on the monitofmeanvery ittLe.lvloreon th s n ihe nextseciion.
a What systemand clrcumstancesare in play?
Are you an experiencedtraumasurgeonworking n a traumacenter
or a generalsurgeonoperaiingin a tent in Africa? How mlch biood
do you have? How good is your anesthesiologist?You musi
incorporateihese considerations into your decision.Damageconifol
is the 'greai eq!a izer"o{ tfaumasurgery,alow ng youto compensaie
for nexperence andlmitedresources.

Damagecontrolis thegreatequalizer
of traumasurgery

The decision to bail out and the physiological envelope

ll the patieri s cLrnentblood pressureis 120/70 wiih good oxygen

saturation,the anesthesiologistwil often tell you the patieni is stable.
What if this patlent
was n shockfor an hour beforeihe operationand lost
an entireblood volumebeforeyou gainedconirol?Are you goingto do a
 surseonn
r The3-Drroumo

'Yes" pleasesay you

lf you answer'
bowel resectionand anastomosis?

:rinrijffi* :i"#;**:6116';F#
:r";';
ver'|J'o
;'"""," m;ss
l,1i#lll,J""''-,"?l;,1':#T"
"T
iJil'iJ""":*iii:lil
i,Bff
:r"L",":*:*1,*n::i:'::::"ffi on the monitofscreen'
Ir*ri"il" ont"i""n'""1 insult,not the numbers
shouldguideYourdecision

ln the damage control

literaiurethefe is much
'lethal
discussiono{ the
triad" of hYPothermia,
coagulopath)/, and acrdosrs
These three Ph]/siological
derangementsmafk the
boundariesof the Patlenls
physiological envelope'
beyond which there is
irreversibLeshock and
death. A core temPeralure
below 32'C during a
trauma laparotomy is
considereduniversallY latal
Unforiunately, in real-liie
lf have a
;;;;;;,0;;t ihe leihal t ad does noi help vou much vou
will bail out well before the
;;;"i;";i srasp of the situation'votr
point ol no relum
p"o"nt'" pf'V"i"f.gi."f envelopeis anywherenearthe
o{ 33"C' a pH of 6 9'
Beino{orcei out o{ the chestby a core temperaiure
is not a sign of good judgmenl You
I J"**"," anesthesiologist
shouldhavebeenout of that chest long ago
""J

Don'tusethe lethaltriadas a guideto bailingout

 TOPKNIFE
TheAd & Crofl of TroumoSL,rgery

Insteadof the lethaltriadj re y on a seres of subileperceptuacues to

rndicaiea developinghostie physlology.

IntraoperativeCues of Hostile Physiology

Edemaof the bowel nrucosa

L/idgutdistension
Duskyserosalsudaces
Tissuescold io the touch
Non compliantswollenabdominalwalJ
D ffuse oozingfrom surgicalincisions

Edemaand distensionof the smallbow€ are relatrvey earlywarning

signs,whereasdiffuseoozingfrom the operaiiveincisions a lateone.

Experenced iraumasurgeonsdecideon damagecontrolwthn minltes

of enieringthe abdomenand sometimesevenbeforemakingihe incisionl
They often recognze a paltern of iijury and physology thai, in their
experience,amost always eads to darnagecontro. N4oreon this n ihe
chapteron thoracoabdominalinjuries.

How well does youl solution fail?

lfyou choose an operativeprof le of definitiverepair,there s usualy

more than ofe repairoption.The iypica dilenrmas beiweena shorter,
simplerrepairanda complexandmoretme-consurning reconsiructon,

When choosingbetweenseveraltechnicalsolutions,considernot only

howwel a padicuar optiof works but, more importaftly,how well ii fals.
Whal w ll happenif the anasiomosisleaks?Whai f the repared spleen
beginsto bleedagain?

Thereis a world of difierencebetweena leakrngcolonicsuture ine and

a fa led pancreaticojejunoslomy.The formeris easly salvagedby proxima
drverson;ihe latteris a muchmoreorninouscomplicaion, not easyio
manage.Can your patienttoleratea failure?A younghealthypatientwlth
 I The 3 D TrournoSlrgeon

(Gl)
an rsolatedbowelrniLlry will suruvea leak {rom a gasiroiniestinal
injuredpatieniln mulii-ofganfailurewill not'
surureline A criiicallv

Choosea definitiverepairoptionthat failswell

Team leadershiP
hole in an iliac
Pictureyourselfgoingheadlo'headwiih an inaccessible
and
tlJ peru:" Your oalier' s n ororounosl'ock
""'" ""*'4"*",i o'ryoJr
blFeoinq aLdo'y.YoLrieamhasore c rcualng lurse DepFnd'ng
your pe'solalized needle
n"',i,"0"""t. ,a" .rr-" *il eilh€rgo nJ'r,i"glor
bites' bring a Fogarty
ariuer ttrat ttas ihe ideal angle {or your next 2_3
free yourfingerfrom compressing ihe bleeder'or
iattooncatleter itratcan
ore
;;,;-;-' a-.olr€1s{usio-'devcewhcn is more impolant? _
p:eceso equrp'ne,rI needeo ar t'r. same Iime
lir""t"tor, ,r'r""
".."niiul
it s your call

Constantlyre_evaluate your prioritiesand your team' adapt to the

excellentsurgeons
situation,and makecomprornises'lt is often said thal
i""" .oo*" wiih a knife and fork' ls the specialclamp you requested
bJr _nedralely
reallvessentia?Ca'r you gel by wirn a 'ess opiimar +en
wn"t *ill vor neeoir live mi'utes? lr mi,lL'es?
""lii"oi" "r".p"
is to siay aheadol
The kevto a smoothand welfcoordinatedoperalion
leastonestepaheadol
tfe oam"les a rut",tt scrubnurseshouldbe at
"
ii"
""0"*i"" at any given mor'ent When you are exposingan lnjured
ue""eL,the nu."" musi alreadyhaveclampsfor pfoximaland disial
".rrb nurse must be at leastlwo steps ahead' riaking
ff't"
"it"ufutlng you will need fot
"oni.i.if1" ,n" FogadyLalloon calheterand the suiures
"rr"
*r"*""a.t ,"pul, ready You, ihe surgeon'must be at least
"ia "r" options Just as in
three steps ;head, consideringyour reconstrLrctive
of the operationyou wrl!
ci"ss, tne bette,play"ryou are,the furtherahead
stay.

Staywellaheadof the operation

 IOP KNItETheArt & Crolt of TroumoSurgery

Maintaina continuousdialoguewith the anesihesiology ieam acrossihe

drape they call 'ihe biood-brainbafrier," and provide them wiih the
iffornrationihey needto stay aheadof the operation.Rememberthat you
are workingin one of severalpotentiallyinjuredcaviiies,and oftenthe only
clue that somethingis amiss in another visceralcompartmentwill be
obviousonly to the anesthesio ogist.TrainyourselJio listento the monitor
whileyouare workingandto pickup anyunusual movesor noiseson the
other side of the blood-brainbarrier.Sometrmesthe nrostcriiicalpart of
the operationis tak ng p ace there, oulsideyour field of vision.While you
cannoisee tj you can trainyoLrrcelf to leel ii.

Frequentchangesin the operaiiveplan are a salientfeatureof surgery

for trauma,and it is your responsibility
to makesure ihat membersof ihe
OR team aro noi left behlndwhen the operativeplan suddenlychanges-
Avoidsurprisesby sharingyourtacticaland strategicdecisionswith them.
Consider,Jor example,the simple act of transportinga damagecontrol
patientto the surgicalirienslvecare unit (SICU).lf the teamis unawareof
your intentionto bail out well in advance,you will find yourselfin the
ridiculols situationof havingjust performeda lightening-speed damage
contfollaparotomy, only to spendar almostequalamounlof time waiiing

Unike chess, trauma surgery is a dynamrcprocess. lr chess, the

pleces are just silt ng there, waitingfor you lo make a move.A trauma
operationmovesforwardrelentlessly whetheryoulikeit or not, confionting
you with rapidy changingsituations.lf you are an effeciive3-D surgeon,
your handling of the tactical, sirateglc, and ieamwork dimensions
translatesinto a smooihand etfectiveprocedure.

THE KEY POINTS

Sterililyis a luxuryin severehemorrhagic

shock.

Alwaysprepfor a worst-case
scenario.

) andpiifallin everyoperative
Knowthekeyrnafeuver siep.
 r The3-DTrcumostrrgeonI

failure
) Avoidflailing;learnto dealwithtechnical

) SimPlify tacticalsituations'
comPlex

of faumasurgery
controlis the "greatequ€lizer"
Damag€
>

) Don'tusethe "lethaltriad'qs a guideto bailingout'

I >
well'
repairoptionthat'fails
Choosea definitive

) Staywellaheadof theoperalion
[ ,o, *",rr rn. on & croflof Trourno
)urgery
 Chapter2
Stop That Bleeding!

Whenezet yot encotnter fiassioe bleeding' the

is: it's not y91!r blood
first thixgio temembet
RaphaelAdar, MD, FACS

Dr' FrancisCarter
In 1989, while discussinga paper on liver injuries'
Nanceol New Orleansmadethe followingcomment:

which has the

"l wauld like to offer Nance's ctassificationof injuries'
at the resident
advantaoe of notneedingto laok at the oryan injured'but
at lhe waundand
who is ;hereat the operatingtable lf he ar she looks
then it is going to do well
vawnsand turnsit o;er b thejuniar resident,
at the injLtrrand
it i" o"Aq n hate a hgh su^ival rat1 he look> tt
somesuturingand
,"ii"l,"r.l.*"t ,""n, ,n;l the 'esidertwill haveto da
be high' and he ar she
reallvhelpthe patient,andthe moiatly ratewitlnot
conference lf the tesident
wil'look gooi during the notuidity'nonatity
will encaunter
sweats...ihatmeansthathe ar shewilt da a lot of sewing'
or herself at the nohiditv'
a coiptication, ara witl nave ta defend hinsetf
-'rf,i"iti,
probabtvreceivea tat at heat And il th. residenl
"or"nn"" for
"rothe anendng the pahent wi do
,na r"^" toLt Ana' hat
".--r"rt'"
(A'n Surg1990;211:673-674)

comes down io a
When vou are operatingon a bleedingpaiient'it all
the patientrunsoul or
simolequestion:can you stop the bleedlngbe{ore
a vascular
is noihowvotrhandle but'
clanrp'
iilJai il'" r."v,o
"r"""ss
ralhef.how vou handleyoursolfand your ieam Bleeding
contfoLLsnot
some cool moves lt is ihe ability to rapidly select
"Oorr'."oJrnn one after the oiher In a
appropriatehe;ostaiic optionsand deployihem
do it
discipiined,eflectivefashion Here s how lo
 TOPKNIfETheAri & Croit of TroumoSurgery

Choosing a hemostaticoption

jump on a bleedingvesselwiththe {irsiavailablectamp.

Don t feflexively
Instead,trainyourselftothinko{ everybLeeding siiuationas a problemthat
requiresan effectivesolution.Thereis alwaysmore than one alternative.
Your job ls to come up wiih a solutionihat will work for the specific
siluationin front of you. Therefore,the first rule of bleedingcontro s
alwaysseJectthe simplest,most expedienihemostaticoptjon.

Beginwith the simplesthemostaticoption

Whal are your opiions?lf you havesome surgicalexperience,your list

musi begin with 'do nolhing.' This is often an excelent choice because
relyng on ntrinsichemosiasisworks surprsinglywell for certainiypes of
minor hemorrhage,like superlicialoozingfrom solid organs.Your list of
optionsprobablygoes on io electrocautery and ligationand ihen gradually
escalates through the use of henrostaticsutures, packrng, batloon
ta..ponade,and all lhe way up to a formalvascularfepair.You will not
inserta hemostatjcsulure unlesssimplermeanshaveeitherfailedor are
inappropraie.Therefofe,the second undeflyingprincipleis a graded

Bleedingcontrolis a gradedresponse

lf the first soution you chose didn'l work, graduallyescalateyour

efforts. An experiencedsurgeon rapidly zoor.s in on the 2-3 best
hernostaticoptons for a given situation.This principle of a graded
response has an importantcorollary:while you deploy a hemosiatic
soluiion,ihnk ahead and preparean alternaiivein case your selected
iechniquedoesf't work. Why is this importanl?

The morecomplexyouf nexthemostaticsolulion,the moretime rt takes

to prepafe.When faced with massivebleedirgfrom an inaccessiblesiie,
preparingan alternativebecomescrucial.l{ your chosensolutiondoesn't
work and you are not readywith an immediatealternative,
you are up the
 2 siop ThotBLeedinslH

i;i;t;:
hemo::1h":iTli,',^1ii
ora paddre,Havins-a
insearch
creek
accideni. lt requires careful plannlngano
they can be iound'
iO"iO*"", V." *ill need and where
"t,""*

Be readywith an altemativehemostaticoptbn

Temporary and definitive control

reakybuckel wr|l- your
Temoora'vcontrolis ,il.epluggng a ho e ir a
"6"t'ii,'"" conitol rs l'ing tne oLrclei ln rassve breedirg
t"".,.
r'r5lsiPpbecarser allowsvouio assess
,eiolr,rv.onrtot 's rt*ays .ne
ii" a"ptoy in appropriatedefinilivehemostaticmeasure'
"ituutlon"nO
atraumaticln certain
Temoorarysolutionsmusl be quick' eifective'and
ft *len tne bleederis eiil er iraccess'be or oifl cL'llto
r '^ta""
(sJch €s pacl'rngor barloon
.1"""r. "1"*" cont'o'lraneuver
""r.I".06"",v ve -Fdsur€
to be tne der'n'|L becduse thFre s no
;;;;;":;t ,n;y ;.,
" "',t s'opoed
oerteropt'on.l{ vo.rLe'npo'ar'ly Packeda oadlyinjJed livera,rdit
,lav€ acl'revedetteclrvelFmoslaqrs
bleedirq,don\ ie-ove rl'e Pachs You
- goodenoughMoveon

Obtaining
tempolarYcontlol
Manualof digitalPressure
is an excellentfirst chorce.
Conirol bleeding from a
cardiac laceraiionwilh Your
{ingef. Pinch a mesenteric
bleederbeiweenlhumb ano
forefinger. Compress a
bleedinginiernaljugularvein
with your finger' lnseri a
finger into a hosing gforn
 TOPKNIFE
TheAd & Crofl of TrournoSurgery

Have your assistant

compress an Injured
liverbeiweenthe palms
of boih hands. Using
your hands is quick,
instirctive, completely
airaumatic,and very

A classicenor of the noviceis to grab a clampand try to blindlyapply

it in a pool of blood.This nevefworks.Vascularclampsare effectivewhen
the larget vessel has been dissectedout and isolated,not when ii has
retraciedinio the tissue or is barelyvisible.Blind clampingis a sign of
panrc.Youwill not onlyfarlio achievecontrol,but also will end up with an
iatrogenicinjury Wild clampingo{ the descendingthoracic aoira caf
easilyresultin an av!lsed iniercostalartery.A clampapptiedhastilyto the
supracelracaortamay perfofatethe esophagus.Blind clampingof a limb
artery in a pool of blood wil crush the adiacent nerve or iniure the
neighboringve n. Uness you are !nusuallytalented,you cannotperforate
lhe esophagusor crush the medianneryewith your f nger

Thefingeris mightierthanthe clamp

Temporarypackingis a good optionfor diffuselybleedingsurfacesor

caviies. lt also frees your hands.However,packingwill not controlmalor
arierialhemorrhage.

Pedicle control is anoiher opiion. Does the lnjured organ have an

immediately accessiblevascularpedicle?The spleen,kidneyand lungdo,
as does the bowel.One of the iwo vascularpedcles of the lver is easiy
accessibleand can be rapidlypinchedbetweenthumb and forefingeror
clamped with a non-crushingclamp, the famous Pringle maneuver.
Similarly,if you mobi|zeihe sp een or kidneyyou can rapidlyconirol the
pedicle with your fingers or a clamp. Twistingthe lung upon itself rs a
simpleand effectivetechniquefor hemorrhagecontrol,asyou wi/ldiscover
later(Chapier11).
 2 stoprhotBreecrine
n

can relaxfor iust a momenl'ger

Temporaryconirol buysyou time You
hand' s!rvey the situationand
,f'""i,Jufu,io" o".f i*o your compressing
decidehow io Proceed

pedicle
olt"r.i* it th,"lt""aing organhas a vascular

Small problem or BIG TROUBLE?

Now tharvo- havegalreotempo-ary conl'o'andbood ' no longer

-eachedthF kev iaclrcal
*r,"" you, olo"r",.u"'rFldyou h've
prob'e'n
," "*r
il"i"'"'" ",i i":.i.*" conrrol:tn" d st ncliol betweend smalr
and BIG TROUBLE

usinga direct hemostatic

A smallproblemis bleedingyou can control
nl"n*""t'fit" clamping,sutr'Lring'or reseciingthe injured ofgan
is a p'troh"ra
H.morrhoqe fror an rriJ-edsp'epnrs a smal'problemaq
ol breedins
;,',;,r"";;;". ; q'ade 'iverrri'rry'Tne sred naror'v
"' " belong In thls
you encounter during a trauma operation
"ir,,"",lon"
category.

BIG TROUBLEis an entrrely differentkenleof fish-a complexor

danger to your
inaccessibLe injury ihat poses a clear and immediate
prototvpeo{ BIG TRoUBLE
p"'""* lii". e'n,nnn*de liverinjurvis the
intercostalariery deep in the
iteeaing from an iliac vein or a posterior
lowerchest are otherexamPles

BIG TROUBLEhingeson
The dlstinctionbehveena smallproblemand
the bleeder'
of the bleedingrate and the accessibiliiyo{
" "".Ui*rt" can bleed more than a
;;;", ;" peripheralmesentericvessels
Yei peripheral
I""t"t.i- n".""rn" in the base ol the mesentery'
theyare accessibleand
.""""t"ti. O""a-" *" a smallproblembecause is BIG
i; d;i;,h. Bleedins fiom the rooi oi the mesenterv
"; {or vascular reparr oi an
in6ugrr u"""r"" lt impliesth€ need
inaccessiblesuperiormeseniericvessel
 TOPKNIfETheArl 6 Croft of TroumoSLrrgery

The upper abdominalaorta s difficultto accessand control;therefore,

a midline supramesocolcher.aioma is atways Btc TROUBLE,
regardlessof how much rt has bled. Free hemofrhagefronj the
retrohepaiicveins ls BIG TROUBLE, not onty because it is fast and
furious,but alsobecauseyou cannotget to ii. Accessibihiy dependson
the patient'sposiiionand on yourincision.For example, an injuryto the
posterior thoracic wall may be inaccessiblefrom an anterolateral
thoracotomyincson, but easy to reach through a posteroaieral
ihoracoiomy,

Learnto distinguishbetweena smallproblemand BIGTROUBLE

Smallproblemsand BIG TROUBLEfequiredifferentmindsetsand

differentoperativeapproaches.Youcan tacklea smallproblemdirectlyby
immediaieLy deployingappropriatehemosiaticsolutionsuntilthe bleedng
stops.One of those soluiionss likelyto work, and the b ood loss wi| be
limited.

lf youj!mp if and go head-to,headwlih Blc TROUBLE,you tose.The

patientis profoundlyhypotensive from niassiveblood loss.The OR ieam
has no idea how bad the stuation rs or how you plan io deal wih it.
Exposufeis bad.The 10-12 unitsof blood the patientwill need afe st tt n
ihe bLoodbank.Thevascularinsifumentsyou will needare sioredoutside
the OR. In otherwords, the odds are overwhelminglysiackedagalnstyou
and your patientevenbeforeyou begin.A frontalaitack (as you did for a
smallproblem), willbe likea bungeejumpwthouta cord.Unlessyou do
someihingto eventhe odds, you'ref nishedbeforeyou siari. So, what to
do? Theanswermaysurpfseyou.
 2 stopIhai BleedinsLI

Update

co'Irol_STOP'Res:stlnetemplalion
OnceyouhavFgainedte-po arv
'ontror' Ins'ead orgarrTeard oprrm:ze
," I-.""a1"*,, p,"J""" to de 'nrLrve
your atiackl

. l"l::T,:",",."jf
il:x'.:JxilJ,",.'fi"1'J"':;ii::J
lnruser'
least8_10unitsof bloodand a raprd
p i-ed and wo'(lng
O Ger an a.rovans us;ondev:ce
; :li:;*".::;"n,::il
fl:"';:11",":ili:1"11:
. "J*m.J1';;x;14 5l;:x:
l+i!ill:.#.'":,,#
likea Foleyor fol
equipmeni
additional
therorreF
handre
'"".' canthev
.- X"'S::"'H"#;;ffi:Jil!:f""";
additional
1""",* l.lJ"ai""at should
vouset u
'',:,:f;::ii::ffiJ'il'"'#J"t'1i11",,*"""*"
f"uFfi"""ning ""r{-

with your
are movingforward'don't fiddle
While all ihese preparations manual pressurer ano
,".o"i"tt L"""" the packsalone'maintain
"""i,J
don t moveanyclamps

Don't fiddle - be a rocx

 TOPKNIfETheArt 8 Croft of TroumoSurgery

Siand calmlyand patientJy wjih your hand on the bteederand wait unril
the ieam is ready,the patienthas been resuscitated,and ihe appropriaie
rnstruments and help are in the field.you havecarefujlyset up youf attack;
now wage your battleunderfavorablecircumstances.

When_dealing
wrthBtc TROUBLE,
resistthetemptation
io keepon
moving.The dramaof exsangLrinating hemorfage rs s(jch rhai the ieam
a\peclsyoulo 'do sometning.
stopo;nglheooeraionin mid-ar-,s l.e lasr
Irrrg theye,oect.Neve.tretess. Instston co_p,erngat prepa.arons even
if it takesa considerableamountof time.We have
occasionailystooa witi
our hand on the bleederfor 15 minutesor more while
the OR ieam
co-'rolelFdp.eparat,ons fo, baflteard -he oat.elt was beingresrscrtatFd.
-are1uF.prepa-at,on ard olannng giveyoJa hugetaclica. eova'rldgF a'ro
dramanca ty improveyourpalents chances,

We cannot overemphasize how criticatit is io distingutshbetweena

smallproblemand Btc TROUBLE_This may we be the most
imporiant
decisiof of the eniire operation.ll is often a sublectrve
decisionthat
oependson your experienceand confidence.A situaiionthat
a surgeon
with limitedtraumaexperiefceconsidersBIG TROUBLE
may turn o"utto
be a smallproblem for an experiencedco eague. Nevertheless, your
if
impress/onis thal ihe situationmerilsan organrzeoattack,you
wiil never
go w-o19oy dporoacri"grt ar Btc TROUBLE.

Alwayserr on the side of caution

Selectedhemostatic techniques

Pdckitlg 701

Packingis one oJ the most underratedand badtytaughtiechniques

in
su]Sery.lt is also one of your best weaponsfof deatingwiih BtG
Ilula
TROUBLE.Surgeonstend to thinkof packingas suchan intuitive
skillthat
they rarelybother to teach it properly.After all, you
don,t have to be a
surgjcalgeniusto stuff some pieces of cjoth afound a bleeding
liver _
wrongl
 2 stoplhot Bleedinsln

packing
is io do ii early.since relieson'clot
Thefitstruleof packing cansiillrorm
l" Jtfectiveif donewhenthepatient
"* ",i,, whenthepatient and
is coagulopathic
n""J"[i'" t"lnan "" " lastresort'
"rril,""l',i
oozingfronr everywhere,is futile

fron withoutis c]eaiiq a

There are two main ways io pack Packing
a cavity
sandwich.Packingfrom lthin is filling

Pack from withoui bY

placinglaPatotomy Pads
outside the rnlured
organ to reaPProximate
disrupi€diissue Planes.
To achieve effective
hemostasis You must
create lwo opposing
pressure vectors that
compress the injured
iissue between ihem;
otherwise,YoutPackrng
)
wlll not wofk. EffeciNe
packingis a sandMch,

livet A good sandwcn

Tn.erecn'1ique" mosl olier used ;n the :nrured
oads {aooveano
arounotl'e live-conssts o'iwo rayerso'laParoto-y
posierior),apptoximaiingthe disrupledtissueplanes
U"to* o,
abdominalwall'
t**"na ,Vefs are suppoded'in lurn' by ihe
"nt"riot
O"*""" *".
organss'icl- as ihe slomachor
i* a:uprlrug,nor by adracentaodom:nar
cn by Laigrrg two p'pces
l^roe bowej. Youcannotc'eate a good sanow
.nust -akc mechanicalsprsF
ni"t,""o ,n n-,0."i-.Vorr
"andwich
 TOPXNIfElhe Ari I Croft of Trourro Surgery

Packirg from wihin is

stuffing a crevice or an
acilvelybleedjngcavitywith
absorptrve gauze.The filling,
consisting of an unfolded
gauze rol, is pushng
ouiwardagainstihe walls of
the injuredparenchyma.

Your packingtechnique
must be iailored to the
shape of the injury. lf
dealing with a large
bleedlngsurfaceor mu tiple
injuriesto a solid organ,
pack fforn without. When packing a beeding crevrce, like ihe deep
perinealwoundof an openpelvicfracture,packfrom within.ln severeliver
injuries,such as a siellatefractufeof the dome oJ the rjght lobe,you will
ottenfind yourself!sing a combinationof bothtechniques.

Packingfrom withoutor withinworksin oDDosite

direction

The thifd rule of packingis io avod overpacking.While constructng

your sandwich around the inlufed liver, pay special atteniion io the
paiieni'sblood pressure.lf it suddenlyplur.metsand the anesihesotogisi
showssignsof distfess,yourpacksmaybe compressingihe inferiorvena
cava (lVC) and diminishingvenousreturnto the heart.Caref| y removea
few packsand reassess.

Toomuchpackingis bad

The fourth (and ast) rule of effeciivepackingis to be paranoid.There

rs aways the dangerthatyourpackswillfot work, bui it usLtaly takestime
to find out. Laparotomypads havean amazingabsorptivecapactty,and ihe
patient may wel/ continueto bleed lnderneath them. lf the patiefi s
physiologyallows,spendat leasta few minutesdoingsomethingelse,and
 2 sroprhoiBleed.q n

t:T;:'il";ift ':T':J
i"J::"::,,,1"if ::;il,:i
-ost
::il":ff;:[';
fsupef;urallayer
ot the
peer.o{i
the
.,"*1,,*.lat U)/".,*" notsJ-e
AreiheyturnrngprnK
l"naiui"t' tul" goodlookat thedeeperlayers youoo nor
" h*e to takethesandwich aparibecause
lij-rno'"tf"na'f *, yo,
mechanlsm
patienfscloiting
n"ueette"tivele.ostasis Neverrelyon the
for ine{fectivepacking The besi time to acheve
i"
"".0"*t"i" r"*" vou leavethe oR' noi iwo hours(and12 undsor
l"#iJJ
blood)Later'
removethe soakedpacks
Whatif yourpackingdoesnt work?Fitst'
more Didyouhavea gooo
*" u1lo""'*a l*p""ithe injuredarea.once
siructures' of did youbuilda
sandiichsotiatysupporiedby surroundlng addmore
"f_to"ting in .id_airwithno support?Do youneedlo
ls lherean
a vouuaa packing{romwithinor lromwlthout?
""na*i"l','
o"'"-f."iSf,ouf it directlv
ii"''"i ,i' tn",",,'"a a'"at lttlre'eis' yo' musidealwiih
techniquecan youdo something eLseto help
,"1"" "-""J* *.*"i'c
ageni?A blindhem.ostalic
i.t',a""""n"i
aii"o'"n" naa a topicathemostatic
"""0
*"t""u *"it ag;in uniilyouare sufethatyouhaveef{ective
"r,lr""
bleedlng conirol

Be paranoidaboutYourPacKs

(figrre of 8) suture
I serting a blittd helnosttltic

a bleederihat is eiiherinvisible
Use a blindhemosiaiicsuiureto conitol
see the bleedernor can you
o, ias retract.a inlo the tissue You cannot usins brrnd
;;; ;;;;;. 'i, but vou can imasinewhefe it is After
emergency surgeryi you
t',".o"tuti" *any iimes in eJective.and
",ltrt"" "o io do ii well Chances are' you
.uv f""i"onfia""t tl"t vou know ho*
don'ii hereare some usefulpointers:
is aPpropriaiefor a blind
a
' Make sure the anatomicalsituation malor
;";;;; lf the bleedingis close to an unexposed
";*".assr.rmethat lhe maior vessel is the bleedet and
"""""i "f*"y"
 TOPKNIFETheAri & Craft of TroumoSurgery

a lJse a monofilamenisuturethat will slide throughthe tissue rather

thansaw ihroughii. Strangeas it mayseem,the keyto successis not
ihe suture,bLrithe sAe ofthe needle.Choosethe biggesineedlethat
is appropriatefor the situation.
a Placeyourfirst biieas close
as possibe to the sil€ of
bleeding.The purpose of
lhls bite is not to achieve
hemosiasis,but to gain a
good purchaseon the tlssue
so youcan littit up by gen y
pulling on the suture wlih
your non-dominant hand.
Nowyou can seeon which
side of your first biie the
bleeder is spurting. Your
nexi biie wrll be for
hemostasis,and since it is
well-targeted,it wil do
usefulwork,
lf anyoneever botheredto teachyou aboutblind hemostaticsutures,
you pfobably know that your aim is to end up with a figure of I
corfigurationthat runs underthe vesse proximallyand distallyto the
bleedingsite. This is nice in theory,but in praciiceyou can neverbe
sure in which directionthe bleedingvesselslies.That'swhy ihey call
i a blind stitch. Don t be disappoinledif you end up needng more
biies. ll is okayto inseri3-4 bitesinsteadof two, as longas the biies
are cose togetherand lhey work. We cal ihis 4-bitesuturea 'figure
of 16.'
a Often, pullingon your blind suturew ll siop the bteedirg.You must
then decide if you wsh to use it merelyas a temporaryhemostaiic
maneuver or te f as a permanent soluUon. lf you decideto tie ii,
remernberto eavethe ends long becauseyou may wish to removet
later.

Whileinserting
a bind stich,planyournexthemostatic alternative.
Experience
hastaughtus ihai il you havenoi obtainedhemostasis
wjih
 2 StopThotBeedins n

ii withihis siitch Don'lJlail'Try

fourbites,you are not likelyto achieve
something else

onthetissue
h..ostatic stitchsainspurchase
filTf,I[of
"

Aottic clafiPittg

heroic maneuversin ifauma

Ao ic clampingis one of the traditional
in a crashinqpatientor
suroerv.Use it eltier as an adiunclto resuscitation
vascularlrauma You are
i*"oriur pt.*i..r contfol in rnajorabdominal
aortai
'-.'i"l' '. i*- r'.. - oroperlvco'rlrolll-esJoraceriacaodom:ndl
LFarnand orauL'ce
V"" .t Ln"li'sr 'ime-ira berlvlul ol blooo
"ti"-oi'i
the lechniqueundereleciivecifcumstances
When used as a
Use aoriic clamping judiciously,noi reflexively
the numberc on the blood
resuscitativeadjunct' ii temporarilycorrects
pfice o{ globalvisceralischemia
0r""""t" t*it"t, O* "t the

As with any maiorbleeding,

the best inrmediately avaibble
tool is Your hand Pull the
stomachdownward and bluntly
enterthe lesseromenlumIn rc
avascular Poi(ion. Feel the
aorta Pulsating imnrediately
below and to lhe right oi the
esophagus,and compress it
againsi the sPine. lt You are
occluding the aona as a
maneuver'
resuscitalive manual
compression is often good
enough. li Yotl need formal
aortic control, Proceed wiih
transabdominal suPracellac
aortrcclamPlng
 TOPKNIFETheArt E Crofj of TroumoSurgery

The keyanaiomlcalconsideration in supraceliacclampingis thatyou are

cjamprngthe lowermostthofacicaorta,but doingit ihroughthe abdomen.
As lt emergesbetweenthe diaphragmattc crura,the aoda is enfotdedby
dense neuraland fibrous tissue. In this particujaraortic segment,it is
difficultto obtaina good purchasewiih a clampwiihoutdissectingaround
the aorta.Yourbest bet, iherefore,is io go higherup, intothe lowerchest.

Clampthe lowerthoracicaortathroughthe abdomen

lf you havetime, mobilizethe

left lateral lobe of the liver by
incising the left triangular
ligament.Thrs improvesyouf
work space bui is not essential
to gei to the aorta.Biuntlyopen
the lesseromentumimmediately
to the rightofthe lessercurveof
ihe slomach, and insert a
Deaver retractor into the hole.
Retraclionof the stomachand
duodenumto the left exposes
lhe posteriorperitoneumof the
lesser sac and, underneathit,
ihe ight crus of the diaphragm.

Palpate the pulsating aorta

abovethe superiorborderof the
pancreas to orient yourself.
Bluntly make a hole in the
posterior periloneum; then,
usingeitheryourJingeror blunt
lipped Mayo scissors,separate
ihe iwo limbsof ihe rightcrus of
ihe diaphragm to expose the
antedor wall of the lowermost
 2 slop rhoi BleedinglI

Usingthe fingets oi Youfleft hand'

lrom
create just enough space on
sides of the aortato accommodate a
you
clamp. That is all the dissection
need.Takean aortic clampano guroe
it io the correci position using the
guide'
fingers ol your leJl hand as a
Clamp,and check ihe distalaortalor

The aortic clamp iends io lall

forward inio the wound Encircle it
with an umbilicaltape and securethe
tape to the drape over the Patrenfs
lower chest to immobilizethe clamp

THE KEY POINTS

) Beginwiih the simpleslhemosiaticopiion

) Bleedingcontrolis a gradedresponse

) Be readywiih an alternativehemostaticoption'

) The fingeris mighiierthanihe clamp

peorcle
> Determineif the bleedingorgan has a vascular

pfoblemand BIG TROUBLE'

) Learnto distinguishbelweena small

) Dont fiddle-be a fock

) Alwayserr on ihe side o{ caution

'fr
to, *"nr rn. ^rt&crofrofTroumo
Jurgery

!
I
 Chapter 3
r -Tt 11,:r
Your VascularloolKlr

haztingthe
'ot,ititu beings,who ate almost utique in
Hutuall
to tria froa th? etpeie (e of olhe$' are atso
i; ;' ; k;i i; i;;; i ;: ;; ;ippi'[ n aisi' cii' ari on to do' o
- DouSlasAdams

'epaira gunsnotinjurylo ihe Iemo-al

lmaoinevoJ'se p,eparlngLo
;;:;;; patienihas ar arte-ioveno'rstisrLlajus' berowIhe
what our
""";;il;
il;is;"i; Yo,ufeel a strons thrill and hear a bruii definitelv
'
residentscall "a greai case
injuredarea Com€ to
You havea smallproblemlno angiogfarnoi the
suture You doni
,l'"0 ot ir, rou have neitherheparinnor monofilament 'aoidly
is becon'ng a
t_"ua o-o"t u"""Llar clamp Yourgreal case
"u"n ools you hdd were
nioit.".". " Ho* wourd you leel ;' the on'y vasuula-
ti* or stra'gnt need'esard a oai- of cr'ide non_
",r"." "utr,res
"orron Can you 'naglnegraobirga sca'pelandlus'g-oirglor
crJshinocrdmps?
ii.l"i-,i"J I l'.'is exactivwnarJ B Mu'ohv dn ama?irqcFicago
"""'" arenovenoLs iistrraarmedolrv
;;;,il;;;;;t H" r xeda remorar
practrcirg vascLlar
ff;;"-"; rro*'eoge ol tne analomv'vea's ol
2 9 rours ano
repai'sIn .he laboralory. and sheergJis Tneoperaiionlook
went smoothlywith no compLlcalons'
arrayof vascular
More ihan a hundredyearslaier,you havea dazzling
vasculartrauma But you
instrumentsat your disposalwhen facing maior
that ii belongsto
.".. i"'"" f"i"fated poPlitealarteryand forget
" contusedlung'
"""""i
a criricattyinlureapatientwho also has a fracturedpelvis'a
and possiblyan inlracranialhemofrhage'
generalpnrc'ples[o
Tn,s cnaoterwil, lr-t acqJarntyou wt1 Lseru
.',.J" *n"n cominglace_lo_lace wth a vasuura'n'ury'We assLmF
"o, i.r. * t. o"iic va.cu ar recnriouesano will show you low lo
J"" =.i
p'esenta u"efrr toolkil
liroi "r."
i"" i" +" u*-. s lJat on secono' we wrll
 TOPKNIFE
TheAd & Croit of TroumoSurgery

of technicaloplionsfor damagecontrol and definittverepair of vascular

injuries.Remember, a good outcome n vasculartraumadepends.fore on
clear thinkingand keepingpiorities slraighi than on cool gadgets and
elegantmoves.Keepyourvasculartookit in mindas you learnto dealwith
specificvasculafinjuriesin subsequentchapters.

Sequenceand pliodties

Much like any oiher trauma operation,avoid making 'excitng

discoveries'when dealingwith majorvascuar inj!ries by followinga we[-
definedsequenceof steps.

Grafr

)J
,<v ,,t,,^ )t ./a-
? I
ogo{_TJ+(fpi
Bleeding Ext€nsile Delinilive Decision
Conlrol Control

Bleedingand schema, ihe two manifestatio.sof vascuar trauma,

representdiffefentpriorities.A bleedingcarolid artery is an immediate
threatto the patienis life, and you must controlit NOWI Not so with an
ischemic eg from a superficralfemoralartery injury,where you have a
w ndow of severalhoursto savethe leg.Th s is why bleedingjs part of the
ABC of the primarysurveyof the injuredpatient,while ischemiaisn't.

Bleedingand ischemiaare differentpriorities

 g vourvoscutor
roolkiiI

Control external bleeding

Obtain initial control ol

externalhemorrhagebY simple
digital or manual Pressure' lf
possible,rapidlyiransler resP'
onsibilityfot comPreasrngrne
bleedingvesselto an aaslstanr,
and preP the hand as Part of
the operaiive field Your
assistantcan then connnu€to
apply pressurewhile Youmake
an incision Proximal io (or
around)ihe comPressinghand
to exposethe iniuredvessol

sourceis deep andthe wound

Usea ballooncatheterwhenthe ble6ding
;;;;;. intransiiron;"J:L?,:::::;^:,1':l:
ffii;;;nd), especia'v
"
groin, supraclavicular fossa'
axilla, or neck. In these
localions,manual compression
is less offeciive.lnsert a Foley
catheter into the bleeding
tract, inflatethe balloonunill
bleeding stoPs, and lhen

(t clamp the main Port of the

Foley.lf the wound is wide
and the balloon PoPs oul'
I \l approximate the wound
\l edges aroundit with a stilch

r* to help holdit in place

bleedingin kansitionzones
-" *n t"aponud" *ntrols external
 TOPKNIFE
TheAd & Crofi of Tro!mo Surgery

Before you begin

Do not beg n a vascularexporaiionwthoui compete knowedge of the

patient'strauma burden. How much iime has passed since the injury?
How much hasthe patienibled? How urgent s the bra n contLtsion? What
is the planfor the fraciureif the extremiiyyou are operatingon? you must
incofporateall thislnformationintoyourdecision-making or you wi end up
wftn an awesomevascularreconsiructron - rn a dead paiieni,

Knowthe patient'stotalkaumaburdenand physiology

Proper sequencingis a huge factor in penpnerarvasculartrauma

becauseinjuriesto |mbs typicallyalsoi/rvolveoones,nervesafd soit trssle.
As a generalrue, bone alignmentconresbefore vasculafrepair.Fixno
fract-resinvo'vess,ch lLnacLvtres as ha. rerirg, rimmrrgandct^isering.
movingbones,and othertricksthata sio suturelinedoes not toleraievery
wpll.So, il lhe hmb s.or grossy 5cremc ard ihe pdnred orhooedi;
procedureis short re.g.erter'lalfrxatronr,let the o.thooediusLrgeor do h
beforethe vasc!larexploration.tfthe timbis grosstyischemicor ifthe injury
is activelybleeding,you haveio go f rst. Controtthe injuredartery,inserta
temporaryshunt,and do a fascioiomyio increaseihe tolerafceof the limb
io ischemra.Let the odhopedicsurgeonachievebone alignmeni,and onty
thendo the deflnitivevascularrepairon a stabteextremity.

Alignbonebeforeaderialreconshuction

Angiography

Preoperativeangography is noi an option for a hemodynamicaly

lrnsiabe or activelybleedingpatent. If a stablepatient,get an angogranr
d you can, especiallyif you aren't sure where the injury s. Consider a
patientwiih multiplegunshotwounds or severalfractlres n the same
extrernity.
How willyou know wherethe injuryis withouta roadmap? With
a srnglepenetratinginjury,ihjngs are sjmplerbecauseyou can find ihe
injurywiih a limitedexploraiion,so you can skip the angiogram.
 3 YourvoscuLorroolkltH

you have
andthe localcitcumstances'
Depending on yourexperience
anangiogram:
threeoptionsfor obtaining

angiograriperformed
1. A single-shot in the ER _ rapidlybecominga
loslan
in the angiographv. strl:
, e"i",r"r studyperformed
_ ":^^9:
couldpreclude
inierveniion ihe needfor openreParr'
-
"ndovascularansiosraphv b1,cannulalion of the exposedaderv
a ;;;;;;" the
"
o""il!"rn" by clamping
oL ai"ned the inflowbeJofeinjectrng
"t"
dv".

;; an angiogramif the patientis stable

Pre-emPtive f asciotomy

beforebeginning the vascularreparr'nol

Considerdoinga fasciotomy on an
*f,i" L clinicallyobviousWhenoperaling
"v"arome repairis goingto take
i""t".""".p"*"""a
,r'ri ,;, .ften knowihai theformal
"ttt, {asciotomy
of actionis to do a pre-empiive
ii"". i""r.
""f""'"""""
Regardless ol your
A poplitealadefy repait is a good examPle'
poprit."it""onstructions alwaysenduptakinglongetthanyou
of
"rp.rlni", in" unforgiving naiure these iniuriesand ihe paucity
-ofguaranteeyor'rwill noi finishthis
"ri"li"o
collaterals aroundihe kneevrrtually
the vascular
;;il il;"i a fasciotomvBe smart Do it before

fasciotomvusing I d:]bl: Jl"l:i::

we do a fourconrpartment
*"';q; Pr""" vour incision
iaterar :tC'*'l"lfll,y-:"1':::::i11"li:
the rasrciaall the way down to the
tateral;o rne edgFo'the tbia OpFn
theinlermuscular
,f,"",'a""ityandincise ::t:l#*f^-+*H
""ni"'
;;;;.;;"; 4t","' Avoidda-ase to rh
"o'p"'i'"'.t'
imityio th of ihe fibula\Then,makea
rve ihat llesl! edgeof
medial
ffie

t<z$ol'.. =r
 cf"^h '<-?tw^
ToPKNIfETheA.t & crofi of Trourno
surgery E

.a
the iibialshaft.Injuryto lhq / ,./
greatersapherfousveiny'nor pad of tnis
/ncrsron,so be cafofulUsrng'lhecautery..6erachthe loleus muscteiro,r1
the modialaspect of ihe tibja to decompressthe deep posterlor
compartment.

Do pre-emptive
fasciotomybeforepoplitearaneryrepair

Extensile exposureand key landmarks

The fundamontalprinciple of vascular explorationis extensjle

exposure,which meansihat you must be able io extendyour incision
proximallyor distallyalongthe same axisas ihe ofiginalincision.The
obvious examplesare
lower extremityincisions
along the medialaspeci
oi the leg. Using ihese
incisions,exposureof
the superftcialfemorai,
popht6al, and Ubial
vessels can easily be
extendedintoeachothor

In ihe upper extremiiy,

subclavian,axiJlaryand
brachial exposures are
similarly extensile. Avoid
non-extensrle exposures,
such as lhe poeteriof
approach lo the popliteal
ve$els or the transaxillary
approachio the axillary
artery, because they limit
your access and restrict
your opiions.
 ToorkilH
3 Yourvosculor

;T"""l"li
l'"3:,i:'::T
..H::1,::::""J l:1iT.-:l
:T'J"'n::;l
:i::;
;:J,::':::iT:fl
:fi:::it'::".m,:*if:i:'
:
":lil;:15::TJl:,""":
;::ii:rtli:l'*::J::"1fi aspccrot tne{emu'or libia'and
a"ria""'t
.;ffi;111"T:J-'j:ff
a+Oq* Findlhe posterior
::;:ll"Jl;
i""'-ff
:*-::rm"""Jff
jT;:iT::'.*:"??"Jt"1li?
t*ff ffio.*"",*": i.,'
;; 'rse{ur whe.vour€ n troubre
concep'
;"i #;;;;j';"
"'tremelv
territorY
unfamiliar

Knowthe key an6tomicallandmarKs

Proximal contlol and anatomical barriers

the accurateplacement ot
What is definitivevascularconlrol?ll is tne
(or olher atraumaiic meansof occlusion) across
u"""ri",
controlis key
i*t* outffo" tractsof an iniuredvessel Proximal
"t"tp"
"nO w[no,, ,''"' oot"'n'nnO'o''tar Lonfo awaylromthe
Fnrrrino a nematoma
blood oss
lt"".li"rr" '" ur"" mislakethai oftenleadsIo excessive
" InlJry' a ld soFetrmes
J^"rn"ti:"a tumor;ngpanc :arogenic

Prevent voJrdrssecton {ro- beco'nlnga searchanooestroym ssion

Il'aI surroundstre
O, orox'r"alconrrolo'risrdetne hematon'a
"it"';"g l" pranes are norrnal and
ti,-t. terrrlorywheretissue
"'"g"
aouan""tow"tdtne n;uredseg-ent
""t:"
giaiua,ty

surgeonsgo beyondanatomical banierslo get proxlmal

Experienced
Manyanatomical
V"", you iu""""J it ' anotherkey concepi
""*rli o{ hematomaconsiderthe
u"t'iersto the expansion
"irultur"" ""*" ""
 TOPKNIFETheArt & Croft of TroumoSurgery

inguinalligamentrn penetrating
injurieslo the groif. Betow the
lrgament youwillfindonlyblood,
sweai, and tears.Above it, you
are in vtrginterritorywhere you
can easly isolateand conirolthe
external iliac artery. The peri-
cafdiumis, similarly,a barrierto
the expansionof a mediaslinal
hematoma,and the diaphragm
blocksthe extensionof a midline
retroperitonealhematoma.Go
to ihe oiher side of anatomrcal
barriers to {ind easy proxima/

A usefulopiionfor proximalcontrolin the limbs,often fofgottenin the

heat of battle,is a pneumatictournrqueton the upper arm or proximal
thigh. Usirg it sar'esolood and sirnplifiesrhe d,ssectio.r.Orce vou have
isolaredand c ampedtrp irlrred vessels.def ate tl-ptoLr'l,qLer.

Get proximalcontroloutsidethe hematoma

Distal control

How importanils distal control? li depends.Usuallypfoximalcontrol

alonedoes not dry up ihe operativefietd becauseback beeding fronrthe
dislaivesselcontinuesto give you grief.The patieniwil not exsangurnaie,
but you will not be ab/eto do a vascularreconstructionin peace.

For ihe aortaand iis proximalbranches(e.g. subclavianand com..on

i|ac arteres), proximalc/ampingserves only to convert fierce audible
bleedinginto weakerbleeding,but you stillcannotsee ihe injurywell, and
ihe patieni is losing blood at an alarmingrate. you mlsi obtaln distal
control.Do ihis outsidoihe hematomaif you can. lf not, exposethe injury
 n
3 YolrvoscuorToorkii

withinthe I'emaloma
unde.pro).ima' conkol andgai4d stalcontrollrom
are the distalrrle-nal
i""'"^i to"rtion, wne-edistarconkol is dfticult
ol thepelvrs
.uu"t,ui"narteryandthe a'ge verrs
"'"loiio"i"rv,
choosethetechnique-thal
Fordistalconirol{romwithinthe hemaioma'
:;i'f
i:"il;",ii;
mt"l';li:xru!T;i"1,fl",;"il1ll'ff connected to a 3'wavstopcock)rnto
l"*# fiol""|lt li"n"rtv cathe-ier
usedin eleclivevasculaf
ffti" l"st technique' frequently
ii"
" "*rV
"rrrr"*i ""tfy"" n"in distalcontrolwithout havingto dissectoutthe
"ff""" "

distalcontrol
u"tloonfor problematic
G"lnillotr.inut

Exploringthe injwed vessel

YoursaJedissection
plane along an artery
, -r ' - .}.::i is the Periadventihal
plane directly on the

Vf-=,,au arterial wall lt will

carry you saJelyfrom
uninjured terrltory lo
the injured segmenl
without laceratingthe
vessel or ripping off
branchos, You know
you are in this sa{e
plane when ]/ou see
arlenal
the pearly_white
wall wiih the vasa-
 IOP KNTFE
TheArt 6 Croft of TroumoSurgery

As you enterthehemaioma,de{inethe injuryby rapidlyansweringthfee

questions:

a Which vesselsare rnvolved?Artery,vein,or both?

a How bad is jt? Lacerationor compteretranseciion?
a Where are you? Are therema]orbranches,joints,or otherstructufes
nearby?

You cannot assess an arterialinjury by externalinspectton.This is

especiallytrue in blunttraumarwherethe arterymay appearintacton the
ouisldeyet hidea disruptedintimaon ihe inside.you mustopenthe artery
and define ihe extent of intimal damage. With few excepiions,your
arteriotomywill be .longitudinal.Make sure you see the full lengthof the
intimaldamage.

Onceyou havedefinedthe intury,carefuy debridethe injuredwaltback

to healthyiissle. Don't compromlseon intlmathat looks ,almostnormal,
or is slghtly bruised,'becauseyou are buyingyourselfand your patient
eanypostoperative thrombosis.Thereare no grey areashere- the rntima
is eitherhealthyor it's not.

Definethe full extentof the vascularinlury

Developing a work space

Remenberihai you are not oxplorlngthe injufedvesseliusi io havea

lool ar,t. You are gor'1glo wo-.( or ir. ano you 'leFd a worl space. A
laparotomyor thoracotomyautomaticaly providesyou with an oper cavty
lhat is your work space. In rhe errremiriesano tl^e rec(, tlere a.6 10
ready-madecavities,so you haveto ca e one out,

Developyour work spacs in siages. First, make ihe incision.Then,

deepenit into the subcutaneous tissueand rncisethe d66p fascra.lnsert
a self-retainingretractor and continue your dissectionto isolate the
neurovascular bundle using ihe key tandmafks.As you make progress,
coninuoustyreassessyouf emergingwork space. ls the incisionlonq
enough? Shoulo yoJ re ocare rhe se{-relainingrefa{,to. ro a oeepe;
 ToorkiEl
3 Yourvoscuror

ffi:Hlii!##
:::ii:+:
H:iH3T*"i"".#
lT,',Ji[$i..""?TJ"T""i"'.1"*Y,"i.
infi:,:H:""j;H' and
l[, ;:::::[:T*, ,neincisionoptimize

developand optimizeyourwolk space

Gradually

The key strategic decision

decision'the choicebetweenvascular
Nowil s tirnefor yourstrategic
aamaoecontrolanddefinitive repair- a simpleenoughconcepi'butotten
a iougndeclslon
repairscome
-epai reouieo Fo'malvascular
Frrsi,consio€tthetyPeof
.n'*oii"*,","i'p"ino:".0 * I "lTllljllii":.i:
quickly
lrnethaicanb€ completed evenuno :?:;:",*:::l';
_
sucha lateralrepairwillwork justdo it
(ormorsihanone) Anend_
anastomosis
A complexrepaiisa\tascular gratt are
a-"nJ a Patchangioplasty an iniePosition
and
"n""toto"i",
:*it,:",:x;ir*:ll:':;;JJ3#i;i:Jl::'i"
;r;'e;';;.';,"ft '; c pateni wno wrlr;ustbreedon and on
unit'
i--',-* tniJPaiieni needsio be in the intensivecare
,t* "..egu'opath
tabrerosins more bood
;;;;;;;; "",r.i" '"""""''"ted not or the ope'at'ns
Ynu'nusl ba l oui
i""ot ng ptog*""'ve'y hvporl'€tric
"'"i
tne paiienl unslableor'acrveLy
Second,consideraddilionalaclors ls
fr"iorg i" ll il'e arswer is ves -damagecont'o,s-your
"n"th*
f:'"XnX'i
"*'ty?
:lll'i::;":"",",::l;J;'R::'"fi::.il"J"',:X corlrol
,"" 0"".*""'l damage
no'aga'nchoose
"tin"""
control
repakanddamage
va3cular
illlilil"",,
"o.otex
 TOPKNIFE
TheAd & Croft oi TroumoSurgery

Vascular damagecontrol techniques

The two majordamagecontroitechniques

for vasculariraumaafe
lJgatron
andshuniinsertion.

Ligetion

Ligationof an injuredvesselis olten a no bfainer.The exlernalcarot/d

artery,celiacaxis,and iniernali iac arteryare obviousexamplesof arteries
that can be ligatedwith impunity.Otherarterles,such as the subclavianor
brachial,can be ligatedwlth a low risk of limb{hreatening
ischemia.lf you
are forcedto bailolt bui planto repairihe vesseltater,don't ligaieii , use
a temporaryshuntinstead.

Ivlosi large veins can be igaied wjih impunityof with accepiable

consequences(suchas leg edema).In ihe past,repaifof the popliiealvein
was vrewed as cr!cial for a good outcome with popliteal adery
reconstruclion,but this sacredcow was slaughteredlongago. Thefeare
even reports ol successfulligationof the podal vein, althoughthis ls
probablyone of ihe very few visceralvelnsihat you shouldrepairif you
can. Remember,ligatinga vesselis not an admissionof defeat;ii can be
a sign oJ good jLrdgment.

Ligationis not an admissionof defeat

Tefiporary sh nts

lf you have liltle vascular experiencebr are operating in austere

circumsiarces,a temporaryshuntmay be your best opiion.Inserta shunl
whenthe patient'sphysiologyis prohibiiive,when orthopedicalignmefiof
the bonesprecedesihe aderialrepair,or when you lack the resourcesto
do a complexreconstructon.

Shunt maierjalis not an issue;use whateveris immediaielyavailable.

We havesuccessfullyusedpiecesof nasogastric
tubes,suciioncatheters,
 3 iourVorcuorroo ht E

preter to use an Argyle snunl

cafotid shunts, and silasticTlubes We and.
sursery'
incarotid
it-resularlv
illil"tr" in"l ir*io""ause weuse Lhemostsoeclacular
casesoi
,; . t" handte.Howeveri-l ore oI
"^"" in he lield'sed
we haveseen a niltdrysurgeon
-ri""".il
"n "" tubeto shunta transectedfemoralarteryin the
l-segment""*,
or naso;astric
grorn.
lnsert the shunt using a
well-defined sequence ol
sieps. Begin bJ/ clearingthe
inflow and outflow tracts of
the injured arlery wrth a
Fogartycaiheter,if availablelf
not, gently squeeze the
proxinraland disialendsof ihe
iransected artery lo exPress
clot, and releasethe clamps
momeniarilyto flush out botl
inflow and outflow Choose a
shuni of the largest d|ameter
ihal will fii comfortablyin the
vessel, trimming it io the
desiredlength.Genily insertLt
into ihe distal, then Proxrmal
artery (since backflow is
in place The simplest
easierto controlthan fore{low).Now, fix ihe shunt
proximallyand distallywith
technioueis to securethe shunito the artery
n"1"" ,"" Howeve- th:s s taumaliu to lhe drle'idlwal a,rdwi| ater
when
,*rit" "ir O"O*emerI of the arteryoeyo']drhe rigalureline
loop twice
tl" snr,r-. ol prelerenceis Io pass a vessel
".a,**,
".1':"."""tne s'runtedarle'yand gent'ycilLh f w1h a largemela'clrpor a
aro:nd
perfusionby lisieningfor a
nrmm"t tournlqret. Now' asless the dislal
Dopplersignaloverthe outilowartery You fe done

io one of the following:

ShuntfailurgshortlyaJtefinsertionis due

a lnadequateinfLow(proximalinjuryor tesidualthrombus)
of the shunt into a
i Compromisedoutflow (residualclot or mlgratlon
disialartetialbranch)
 TOPKNIfETheAd & Croftof TroumoSurgery

a Obstructed shunt(angulatron
dueto excessive lengthor ligatures
ihat
aretoo trghil.
a Shuntdislodgemeni (presents
as a rapidlyexpandinghematoma).

Clearlhe inflowand outflowhacts beloreshuntinsertion

Def initive repail techniques

You have ihree opiions for definitiverepafii endio-end anasiomosis,

palch angioplasiy,or interposriiongraft. An end-to-endanastomosis
sounds like an gxcellent choice because rt involves only a single
straightforwardsutlre lire. Ljnfodunately,with experienceyou will lind
yourself using this solutior less frequentlyihan you think. In young
patients,the ends of transeciedarieries retract a surprisingdistance,
creannga largegap.The inexperienced surgeonwil spendt me mobilizing
bothends of the transeciedaftoryin a herolceffortto bnngthemtogether
This entailsadd tonal dissectionand sacrificingbranchesatongthe way.
Despitethese afforts,the resultingend-toend anastomosiswill often be
underconsiderabletensionand will haveio be redone,this time usingan
interpositiongraft. Therefore,in vasculartrauma, the best opiion for
compleietransectionof an arteryis often an interposition
graft,

artery= interposition
Transected graft

Patchangioplastyis an optlonto keep in mind,especiatlyif at leasthatf

the circumferenceof the arteryis still intactor if the vesse is small.We
rarelyrepaira lacerationtn a brachialor popliiealarterywthout a small
vein patch,becauseevena transversey oienied latera repaf wi I narrow
the lumenof lhese smal vessels,

Before you begin ihe reparr,pass a Fogartycatheterproximallyand

disially,and then flush the vesse with heparinizedsaiine.The Fogariy
catheierwlll not only evacuatecoi, but aso will dilatea spasticvessel,
facilitatingyour repair.
 To"rkig
3 /ourvoscuro

vasculaftrauma'raisingfears
Systemicheparinhas a bad reputationin
soft {rssueor In remore
o'clusing U'eea,ngIn Ihe adlacenttrdumatiTed
especiallyil
'ni, nes.Hlowever,wfrendeal:ngwrh an isolat€oarler;alInjury'
t"o"', n"t"n rime'givesystemc heoajn to proteclIl'e d;stal
tir,
'microcirculation
" " "ke ariery repairs are a good examplewhere
Popliteal
sysiemicheparinmakesa difference
rol a mJsl ll a vein
Oo vou l'ave Io tepair injuredveins?lt is a 'urury
ine toJble These
,. i"*i'"" a co.pre* ,epai' t may not be wonh
" often
,J""1t" t""n"tnrt rno'ederand'ng lhanarte'ialreconsrruclions
"]" lr Ih€ palientl'as
*in *tencv' and mav oe 'nnecessatv
"i"t"i"""J,'i sustaneo a srgn lcant physiorogical
.ti* ti" ,"qui,"
w'thoul
'"""rr,
"'r""" t'" oR {or manyhouts' ligaielhe Inluredve n
"""ntion
"ih"]0""" "
hesitaton.
venousreparr'lhe
l{ vou decid€ Io iaduge i.] a combinodarleria'ard
because a thrombosedven
u"nou" ,"con"tru"rio't should come {irsl
tissue
o" cleared R6membefio interposeviablesoil
"ff".tiu"fy a fislula
Setweenthe ve"ous and arieial tepars Io nreveni
"""noi

Veinrepairb a luxury- not a musl

Working with grafts

vasculatirauma No
Choce ol qrah malerrarrs a mapr collroversy n
Io the
.""' ;J";"" a syntherrclrair oelow ll-e Lnee or drstar
""t *ssels are ioo small;4mm syniheticgrafts simPly
i"""r"",n"
"l"rfa.t on the femoral artery The
a.nii *o*.. ft,i" locuses the controversy
worK altho'lghLl'ereis
irooon"nr" ot u"in sr"ft" emphas'zehow wel' Ih€y
gra+s ri young
.n .ooa ev'derce ihat ll_ey do beiter il'al synthet;c
;:;;*';;;"t;"t oufrow trac$ rhe p'oponents ot sJnlhet:csta{is
nleclion and
:;;;; ;; ;" Ihev rarl s nce n Ihe preserce ol :n sudden
resLr't:ns
.;;" sta{i ;essicatesano.dssolves
";;":;;. gradual'y by lormng a
hemorrhaqe.A syrthetc gralt iails
oseudoaneu'Ysm
-o"r"o* A4oIl'eraovanlageo'1he syllhetc graft is €{pedlercy
lemoral artery
Lr, prelerence rs synthetrcgrah lor
 TOPKNIfElhe Art & Crofl of TroumoSurgery

reconstruction.The tfuth is thai i does not matterwhich materiaiyouuse,

as long as you do it well.

Graft proteciion is a cardinal principle in vascLrlartrauma. When

ptanntngyour reconstruciion,fememberthat an interposiiiongraft in a
traumatrzed and coniaminatedfleld inviiosdisaster.you haveio routethe
gratt througha clean fieid or cover it wth wellvascularizedsofi tissue.
Graft protection considerationsmay dictate ihe operaiive sequencel
bowel repair and peritonealtoiet before an abdomlnalvascular
sofl trssuedebrdementbeforean jnterpositiongraft in an
reconsiructron;
Injured extremity. Occastonally, yo! may have to improvise an
unconventronalextra,anatomic routefor the graft to avoideithera heaviy
contaminatedenvironment or a largesoft irssuedefeci,

Vasculartraur.a js esseniiallythe art of deatingwiih youngarteriesthat

are sofi, pliable,and easilyundergovasoconstriction. Rememberthese
rnherentqualrteswhensewingin a gfaft.The technicalprincipe of driving
the needle always from inside the artery out, so religiouslytaught in
eleciivevasculafs!rgery,ls trrelevantin vasculartrauma.you won't raise
an rnlimalflap in a healthyartery,6van if you go lrom outsidein. So, work
rn whateverdirectionis nrosl convenrent,but always have tremendous
respectfor the arteral wal, becauseii will not forgivebad passageoJthe
needleor jefklng the suturesideways.The trajectoryof ihe needlemusi
alwaysbe perpendicular to the arieral wall.

Do not injurethe arterywith your vascularinstrumenis.pass a Fogarty

catheteronly a few cent rnetersaboveand below the injury,and do not
over'inflaie,or you wil denlde the healthyiniima. Close the iaws of a
vascularclampgently('onlytwo clicks")so as not io crushthe artefy.

A majorpilJallwith yourg arieriesis s/zemismatch.lt ls easyio insert

too smalla graft intoa vasoconstricted artery,ontyto laier reatizeyou have
createda boiUeneckthat inviiesearlyfailure.This is particulafycommon
in the aortaand i|ac arteriesofyoungadults.Becausethe vasoconstricted
aortawill dilatelater,makea consctousdecsion io selecta slightlylarger
graftthan whai you deem necessaryat the moment.

Vasculartr6uma is the art of dealing with healthy aderies

 3 Yourvoscuo,rooLkll

THE KEY POINTS

) Bleeding aredifferenlpiorilies
andischemia
in lfans(ronzones
bleeding
conirolsexternal
> Balloontamponade

physrology'
) Knowthe patienis ioialtraumaburdenand

) Alignbonebefotearierialreconstrucliofl

) if the patientis stable

Getan angiogfam

fascioiomy
Do pre-emplive arieryreparr'
beforepopliieal
)

> landmarks'
Knowthekeyanatomical

) conlroloutsidethe hematoma
Get pfoximal
dlsialcontrol
balloonfor problematic
Usean iniralumlnal
)
lnlury
De{ineihe fullexientof ihe vascular
>
yourworkspace
developandoptimize
Gradually
)
repairanddamagecontrol
Decidebetweencomplexvascular
)

> of defeai'
Ligationis noi anadmission

) Clearihe inflowandoutflowtractsbeforeshuntinsertion
gra{t'
artery= interposition
Transected
)

) Veinrepairis a luxury- noi a must

t iraumais the artol dealingwithhealihyarteries

Vascular
TOPKNIFE
TheArt & Croft of TroumoSurgery
 Chapter4
The CrashLaParotomY

full speedahead!
Damnthe totpedoes,
Admiral David l. Faragut

In mostsurgicaltraining programs,you sp€ndmuchtime in the OR with

,^-.,,*".v in nand.merrirv braslrnqawayat 5uayeynrocfes whileyoLr
wilh a r'gl-t-a-gled
i",.1# ,,i"o"rt'""'t op"ns tl^e correctliss'reo'anes
*cl"r Irp or ar educated {'nqer'pretendlngyou a'e
r"
"i]-. """oot""""t*"t a'ranserelraclon and
-_r.r;e,a"
Ii"| vo- cut ss''e . tie trots
""""1t* ol ge'e'al sLIgef
oowe, are all parl ol In" tecnrrcdllargudge
_oI an acce'e'ated v€rs'on oI the elect've
A rrauma operarror is
rmoortantly'
.r*"irr" it .-tr'r"" o tlerell I"cnn cdl langLagea'rd moct
" tnFsed'{erenccsby
I ii"r""trnnd""t ln thischdpler'we dero'sirale
and translaiinglt Into
Lilng r";irl"t op"t"tlon' exploraiorylaparotomy'
" Rapid alternationsbetween
ifre tleclnicat anguage of traurfa surgery rhe
-a_euversa.rd reliculous dlssectonare
"*n-","a" "*-""tt" nparolonvll's likedancingthrougha Iearm ne{ield
i"'."""""i"i'ir",
pictufe?
*iii. pi.yl"soOOL/- onvourlaptopGetthe

The oPerativesequence
same methodical' pfactLced
Every trauma laparotomyfollows lhe
operatNesequence
Repair
oeflnitive

.r ^'fib

/"r
\,t("
rr\"€ - +,0;;;;1
\ r-++^-
Tenporary I Expro€tion
Bleoding
"\y:
Exposue Control
oamagsControl
E to, *",r, tnuon & crotiof TroL,rno
surserv

The keydecisionin ihis algorithmis the chojcebetweendefinitiverepair

an0 dan'iageconirol.The earlieryou makethis decision,the better
for ihe
patieni.

Gaining access

Enter the periionealcavityihrough a long mid/ineincisron,the Texas

namefor whichis 'Hey diddlediddte,rightdown the middte.,, The tess
stabe the paiient,the fasteryoushoulddivejn. Takeihe scalpelandmake
a bold cut throughthe skin and subcutaneous tissue.lf you grab the
djaihermyto systematicaily barbequesubcuianeousbleedersIn a patient
wilh a systolicpressureof 60, you are probabtyin the wrongspeciattyand
should consider a career change. The hypotensivetraunrapatieni is
peripherally
vasoconstricted, and you are wastingtime orj nonsenseoozng
wnilerapidintra-abdominal bleedlngcontinuesunabaied2cm belowthe tip
oJyoLrrdiathermy. Soundsprettyst!pid becauseI |s.

Theincision beginsbelowthexiphoid, skrrtsaroundthe umbilicus, and

ends above ihe pubis. An experiencedsurgeon uses ihree long and
precisepassesof the knifeto enterthe peritonealcavity.The first sweep
gets you pastthe skinand intoihe subcutaneous tissue.The secondpass
landsyou on the lirieaalba. Developthe abiliiyto gaugethe depih of th€
subcutaneous fat and ihe 'feel"of landingon the fasciawitholt cuiting it.
The third and last pass of ihe knife dividesihe lineaalba to visualizeihe
prepentonealfat.
 4 The Crosh Lopororomy

a pro lr'r la(es Yo'llrveor si\

Tra:nyours"llto ma^etne ncisonl:Ke
lo'prrmet'"e'
.*""p".'yo, a- or.ayO,t notyet ready
in the abdom'nal wa'l ic
The kev-anF.rver.s 10cul thFmiol:newhe'e
lhe
,n,nn"'",llo ,neaboome":s qLlckestTnisrs calleo"garnirg
""ur'n,o of the midlineis the decussationoJthe fibers ot
n"jr"*"
",,0i,"".,iO underneathyour fascial
tt" unt.rioir""tu" sheaih lf you see muscle
incision,sieer medially

Now,take advantageoi
a little-knownanatomrca
faci. In most Paiients,the
periioneumjust cranialto
the umbilicus is either
verythin ot has a delect
There is only very thin =
preperitonealfat in thrs =-
area, makinglt the ideal =
'-- - - ---
enor for enterirq the
peritonealcaviiy forca "=.:;==;-2')
the elaboraie dance ='
(often iaught in elective
surgery) of Picklng uP
'wo parrso{ p c{'p- ard makirgd s'all n:c\ lo
rh-"-oe;itone ,m betwee.
defeclimmedralely dbovF
l"iju-;. 5r-p1 po^ea frrqerirro rl-isoer'tone't
tf'" u*lifi"u", yo, find yourselfin lhe peritonealcavlty
"na
pFrfioreu_1toge'he-wrth rhe
tlsinq a parr ol l^F€vyscissors crr Ihe
Useyourron-
-J,n"o or"p"tito.""riai'Loll'e rullexlento{ the:ncision
pusn ine IntesrilFs oown Io prolecttnem tor youl
i".i'""i,i,"a'o
it between
.i".""i"g ldeniiJythe {alciformligamentand divide
bellv'
;;;;
""i**"
; ;;'; to ih" tishi uppet quadrant You fe in the
""""""
readyto Rock n' Roll

finger
ot theknifeandoneeducated
ttr"e sweeps
ilf,Ih" u"tly
"itt
 TOPKNIfETheAd & Croft of TrournoSu€ery

A 7oor.1 of cdlttion

Tl_e.maior_pil'allouringa crasr laoarororvis,arrogFnic:njury. Theteh

lalerdllobe or -he l,ver rne srah bowet.ano thF braodF,a.e in j;oparoy
n
ihe upper, mjddle, and lower parts of the incisjon,respectiveJy. On a
particularlybad day or if you are especiay gifted,you can jnjufeall rhree
otgansin one bold sweep.

lf the patieni has a pelvic fracture, entering a pelvic hematomais

generaly considered a bad move. IVake an upper midline incision,
carefullypeek into ihe abdomen,and extendyour incisiondownward
belowihe umbilicus underdirectvision.

Enlerlngthe abdomenthrougha pfeviouslaparotomyscar can be time

consumrngand exasperating in a hypoiensivepatient.The safetechnique
is io extendthe lncisionbeyondthe old scar into virginteffiioryand enter
the peritonealcavitywhere adhesionsare tess tikety.Then,oper the otd
scar piecemeal,after making sure that ihe lndersurface s clear and
pushing adhereni loops of bowel out of ihe way. Even if you have
completedyour incisionwithoutmjshap,you may still face adhesronsof
bowel loops to the anteriorabdominalwall. When these adhesionsare
dense or mult/pie,you will feel a liitle stupid engaging in careful
adhesiolysis whilethe anesthesiologistis punrpingunii after unji of blood
intoyour hypotensivepatient.ls there a quickerway rn? yes, there is.

A creative solution in an
abdomenwith multipleold scars
would be noi to enier in the
midline, bui make a biiateral
s!bcostal incision (also known
as a DoubleKocheror a rooftop
incision).The inclsion iiself
takes longerto makeand close,
but you will morethan make up
for il by skirting around the
troublesomemidlineadhesions.

Stayawayfrom old scars

 4 ThecroshLoporotomy
Il

Once inside the abdomen

all you can see is a
When you firsi peekinto the open abdomen'
of fo*"f top" swimming in a poolof bloodandclols YourfLrst
"p"gi"ni hemostasis andevacuate the bLoodso
iiloi,ti"" to u"t,i"u"temporary
"r"
yollcanseewhatis golngon

The key manelver

raw is eviscetation
Rapidly gaiher ihe
smaLl bowel loops
outside ihe abdomen
ioward you (io the
right and uP) Don't
just shove laparotomy
pads inio lhe oPen
abdomenwlthoutevis'
ceratingthe bowel,an
act akin to throwing
paper naPkinslnio a
bowelo{ soup - and a
total wasie of iime
a manageablework space,
Eviscerationconvertsthe boody mess inlo
Rapldlyevacuatethe blood and
allowingyou to see whal you are dorng'
achievetemporafyhemosiasis

the bowelearly
Eviscerate

basedon the mechanismol

Choosea iemporaryhemostaiiciechnique
-rat-mabegi,]w'in empi'caroacli,rg Handyourassisianl
nurv.In or.r'rl
eaunqLaoralri- IUrn
, 1i"" '**"t"' to e'eva; ltseabdo-rralwa ' ol
'aprd'vBegi' wittslne 'igl'' LpperqJad a,trbv
i".. ,"" gentrvloward
".i
.,"1'i] *,, t*o ou", 'n" ao-" ol the 'rve pJl ng ''
"Oo"-""
ano iFen oelow Ir e l:ver'
;; #;,;t "r, pac\s overvo ' nanoa'ove
N'4oveto iheleftandputyour non-dorninant
i,""kli" iionto"'"*," nutter'
n"nJ tf'" it gently
pulling lowardyou'ihenpackoveryour
"fou" "pf""n'
 TOPKNIFE
TheArt & Crafi of TroLJma
Surgery

reiractinghand above
the spleenand left lobe
of the iver. Create a
sandwich by packing
medial io the spleen.
lVoveto the leftparacolic
guiier and then to ihe
pervrs,and pack them,
Al this tinre, the evis-
cerated bowel remains
out of the way.lf blood is
accumulating on the
evsceratedbowel, the
source is a mesenleric
bleeder. Deal wiih it
drrectly.During packing
and while your non-
dominanthandis retfactrngand proiectingthe liverand spJeen,
fee/for any
obviousinjury,and begin planningyour approachbased on this tactile

Empirical abdominal packing does fot arrest major arteria

hemofihage.lt gives yo! time to organizeyour efiort and divides ihe
peritonealcavity
intoseveraldislinctareasyou can exploresystematically.
Packlngworkswel n blunttralma becausethe most likelysourcesof
hemorrhageare the lver, spleenand mesentery.Bleedingfrom most solid
organinjuriescan be temporarily controlledwith ocal pressure,while
mesentericinjuriesare immediatelyapparent in the evlsceratedbowel

In blunt trauma, begin with empirical packing

In penetratrng
lrauma,yourbest bet is to go straightai the bleeder
Glanceinto the evisceratedperitoneal cavityto deierminewherethe
bleedingis comingfrom.Youwillthenbe ableio achieve iafqetedrather
lra. bl:ndrempora.y herosrasis.pac^ a b,eeding sohdorguno,,
 4 The Crosh Loporoiomy

containedretroperitoneal hematoma'Manuallycompressa {reelybleeding

u""""i. Ct"rnp bleedet some surgeonspack empiricallyin
penetrating traurnacases,just asthey do in blunttraumaWe preierto see
"."""n,eric

eracilywhat is bleedingand addressit directlr'

In an exsanguinatingPaiieni,
consider compressingihe aorta.
i Manual compression of the
supraceliacaortathrougha,ho!eIn
I the lesseromenlumrs mucn sarcr
and as ef{ective as formal
clamping. Transfer responsibility
for aoriic compressionto the righi
handof your assrsianl

trauma,eviscerateand go for the bleeder

In penetrating

Surveying the battlef ield

Once major bleeding is

temporarilycontrolled,raPidL)/
explore the abdomen The
ifansversecoloneltendsacross
the middleof Yourincislon,and
its mesentery divides the
peritoneal cavity into two -
visceral compartments The
supramesocoliccomParlment
coniainsthe liver,stomach'and
spleen, The inframesocoLlc
conrpartmertcontainsthe small
bowel, colon, bladder, and
femalereproduciive organs
 TOPKNIFE
TheArt & Croli of TroumoSurgery

Systematicallyexplorethe peritonealcaviiy.It doesn,tmatterwhereyou

begin as long as you maintaina iinearsequencethat covers the enlire
conieni of both conrpartments.Thls sequence sholld be rouiine and
reproducible.You learn it in residencyand methodicallyrepeat
it in
subsequentoperations,ln your sleep (andjn courr).

Beginyour explorationof the infranresocolic

comparrmentby tiftingihe
transversecolon craniallyand funningthe gut irom the ligamentof Treitz
down io the rectum (or from the rectum backwardsto the ligamentof
Treitz).

Two pairs of hands ,

yoursard yourassistant's
' {lp eachloopof bowelin
a coordinatedfashionto
inspectbothsjdes,paying
special attention to ihe
mesenteryThe posierror
aspect ol the transverse
colonand the hepaticand
splenicflexuresare notor-
ious for mrssednjurjes.lf
you rdentjfy a bowel
perioratron, contro the
spillagewith a soft bowel
clamp.Youtypical/ysmella colonicperforation
b€foreyou see it. Remember
to lookai the bladderafd fematereproduciive
organsin ihe pelvts.

Pull lhe hansverse colon caudad to explore the supramesocolic

compartmenl.Inspectand palpatethe llver and gallbladder,and palpate
ihe fight kidney. Then, inspect the stomach all ihe way up 10 the
esophagogastric (EG)junciionand the duodenum(includingwhai you can
see of the duodenalloop).To fullyvisualizethe duodenum,you musi do a
Kocher maneuverand take down the ligamentof Treiiz. palpale the
convexityof ihe spleenand ihe left kidney.Don,t forget to inspeci both
hemidiaphragms and noteany injury,as wetl as whetherthe diaphragmis
flator bulgingintothe abdomen.
 4 The Crosh LopororomY

Next, exPlore ihe

lesser sac. As Your
assistant holds uP the
stomach and transverse
colon,Pullingthem aPan
to streich the greater
omentum,go to the leti
side of the omentum(it is
typicallyless vascular),
and bluntlyPokea holein
ii. Thisallowsa good look
ai the posteriorwallof lhe
stomach and the body
and tail of lhe pancreas.

compartments
and inframesocolic
Explorethe supramesocolic

the
So far, you have exploredlhe petitonealcavity-Underneath'
is still lurkingin the
r"t;;"'-ft"";;., a sepa;atevisceralcompartment'

Exploring the retroPeritoneum

To get to the relro_

peritonealsiruciures,You
must go behlrd the
intraperitoneal ofgans
Global exPosureot the
entire retroperitoneum s
lmpossible,so the key
principle is limited
exposureof the relevant
retropeton-aalsiftlcures
by rotatingthe overlyrng
intraperitonealorgans
medially.
 TOPKNIFElhe Art & CroJtof TroumoSurgery

Decidewhjch retroperitoneal structureyou wjsh to explore,guidedby

.
clinicalsuspicionthat it may be lnjured.your clinica suspicionis basedo;
the tralectory of the wounding missije or on the presence of
a
retroperiionealhematoma.For example,any hematomaor blood staininq
arou'ldrheouodenatoop mandates mooi,izd-iorol-he seLondpa|.or tr;
duodenum and the head of ihe pancreas. penetratinginjury to the
ascendrngor descendingcolon requnesmobitization of ihe enrireinjured
side of the colon io examinenoi only its posteriorwall, but also the
adlacent uretet How can you get the intraperitonealorgans off the
underlyingretropefiioneum? By doing a medialvisceralroiaiion.

Keep rehoperitonealexplorationtargeted and limited

Lefl6ided rredlalvisceral rotation (Mattox maneuver)

.
The east accessible area of the retroperitoneums the mldljne
supfamesocottcsector, which contains the suprarenalaorta and its
branches.lf you iry to get to the slprarenalaortadirecilyfrom the front,
you will have to transectthe stomachand pancreasafd then struggle
throughihe denseconnectivetissueand nerveplexusessurroundinoihe
aona.The [,4€tio'maneuve.altowsyoJ lo ducomoishrh,serpo,ure s-p y
by liftingthe left-sidedabdomiiatvisceraoff ihe posteriorabdominatwail
and rolingthemio the fghi.

Begin by mobilizingthe
lowerdescendingcolon,as in
a left coleclomy.Pu I the left
colontowardyou, ideniifyand
incise the white iine of Toldt,
and rapidly mobilize the
descendingcolon from below
toward the splenic flexure.
Continueyour move upward
along ihe same line, which
exiendslateralto the spleen.
 4 TheCroshLoparoromy

This moveenablesYou
to roiaie ihe spleen,
pancreasand left kdney
in a media direction
toward the midline As
your hand sweeps rrom
below upward and
mediallybehind the lett-
sided organs,Your Plane
is directlyon the muscles
of ihe posteriorabdominal

ln most srtuatrons
requiringthis maneuver,
hema_
the retroperlioneal
toma wilLdo much of the
lifls
dissectionfor you. As it spreads laterally'the expandinghematoma
you to
the lefi sided ;iscera off ihe posteriorabdominalwall, allowing
performthe maneuver bluntLy and rapidly

you
An expandingcentral hematomadoes the disseclionfor

You know you are In

the correcl planeas long
as You can feel the
posieriorabdominalwal!
agalnst Your fingediPs
whileyou bluntlydissect
behind ihe viscera with
your hand. Continuethe
medlalrotaiionallthe way
up to the diaPhagmatc
hiatus.You can then cut
the left diaphragmatic
cfus laterally,and bluntly
dissectaroundthe aorta
E ,o, *"nr,n" o,r& crofiorTroumo
su,sery

wrth your fingerto gain accessto the distalihofacicaoda

as high as T6.
This is a quick and easy way to gain proximataorric
coniroi wjihout
openrn9li.F chest.The comp,etedl\4atiormaneuvergivesyou
acLessto
ihe abdominalaorta as wellasmostof its branches, includino
the celiac
suoF.iorme<entFr.c, re,,,enatano tefli,iacaneries.

ll your target is the ao*a itselfor its anteriorbranches,rotaiethe left

kidneywith the otherleft-sidedorgans.lf you leavethe kidneyjn place
by
deveroprngyour ptaneanteriorio it, you will restrictyour access to ihe
anterolateral aspect of the aorta.The left renal vein and arterywill be in
your way, and the JeftureterwitJbe vutnerabte ro injury.However,if your
larget js lhe left kidneyor the renalvessels,leaveihe kidnevin olace.

Feelthe musclesof the backagainstyourfingertips

When you performthe N4attox maneuverfor the firsi iime, you discover
(yet again) a discfepancybeiween neat illusifationsand harsh realitv.
Don'i say we didnt wa,1 yor.r.Once you nave cla,nped rhe aor;
proximally, it becomesa pulselessflaccidtube that is difficuhio identjfvin
a largeretooeritoneallemaLoma.To -a1e maflersworse,a tnick laveiof
periaortictissue separalF5ihe suprarera, aorla l.o7l your dssectior
plane,and you musi divideit to gain the periaoriicplane.We advisevou
to ga n t,rrsolaneai tne irJrarenalleve,,whe.p it is much easierto toeniifv.
and tnen orocFed uo to rhe sup-arenataorric segmerr. tr youni
hypoiensivetfauma patients,the aoria is constrictedand considefablv
smalefihanyouexpecl.

It is not uncommonto injureihe spleen duringa rapid medialvisceral

rotaiion,so examineit closely when you have iinished the manelver
Anotherclassicpitfaliis avulsionof the left descendinglumbarvein while
mobilizingthe left kidney.This treacherousvein comes off ihe left reral
vein (LRV) and crosses over the left latera/ aspeci of the aorta
immediaielybelow the left renal artery.lf you plar io work on ihe aorta
around the level of ihe left renal vessels,it is a good idea to idenitfy,
ligate,and djvidethis lumbarveinto avoidavulsjondurinoretractionofthe
mobilizedleft kidney.

j i.Jl L\,,/)rA
 4 rhecroshLoporotomv
rl

Right-sided medial viscelal lotation "

medialvisceralrotationin three distinctslaqes'
Performrighl_sided
Eachsuccessivestagegivesyou progressively belterexposureol tne

The first stage is the

classicKochermaneuver,
where you mobillzelhe
duodenalloop and head
of ihe pancreas ldentify
the duodenumand Incse
ihe posteriorPeriloneum
immediatelylaieralio it.
Insinuate Yolrr hand
behind the duodenum
andheadof the Pancreas
to begin liftingthom uP,
anJ c"ontinue'molitizing the duodenalloop fiom the common bib duci
(SN4V)inferiorlyThe hepatc
superiorlyto the superiormesenlericvein
haveto
ttexureoverliesthe lower part of the duodenalloop' and you may
and head of the
mobillzeit too Now you can tefleci ihe duodenalloop
oancreasmediallyto see the IVC and
the right renalhilum Bewareof injury
to ihe right gonadalvein as rt eniefs
ihe IVC at ihis level

The second stage of a righi_sided

medial visceral roiation is the
exiended Kocher maneuver,which
gives you wider exposureol the
retropefitoneum.After completinglhe
Kochermaneuver, carrythe incisionin
the posteriorperiioneumin a caudal
direction toward the white line ot
Toldt, immediatelylaterallo the nght
colon. Note that this white line is in
E ,o, *",rr rnuon & crofjofTroumo
susery

;:|,.ff"",dt:irlHr;::##:"ffiil1^i".
;Til:ifln: :",;"T:::;: *::i:"'"'",'""n.,'*iiJ,
;i;,il;l:
Doarisht.sided
mediar
ni"""J.IiIiIIiIt"-!"!
stage is, you guessedit, a super.exiended
_^ll: ]n|:O Kocher

Fri:{,ili:iiJi:,ili"]ii:",1""#,3
i:ri:[:]r, iffi ::"."#::t,ff
il;;l;i*m*iri
c'ania'rv
aroobJq*'v
r'o''rn.
;
;:'il1;:iT".li";;"'"rero' J
"*u-
To perfom the Catiell_Braasch
maneuve(do an extendedKocher
maneuver;ihen, carryihe incision
in the posteriorperiioneumaround
the cecum.Now, gatherthe small
bowel 10 the rjght and craaiallv,
and incisethe tineof fusionof th;
small boweJ mesentery to ihe
posterior peritoneum from ihe
medialside of the cecum to ihe
ligamentof Treitz,a surprisjnolv
shortdistance.you shoutdnowie
able to brjng the smallboweJand
flgnl coton out of the abdonren
and swing them upwardonio the
ameaordrest, a prettyremarkabje
srght.

maneuver beginsar ihe commonbr/educi (CBD)

---]h:--C.n:,tp*i*h
ano ends at the ligamentof Treiiz.When
p-anoramic
vrew
orriee",''."r,,"."""""i" ,"1i#0"',"J"'L,l rJl"rt":::":
to the infrarenalaortaand lVC, as wellas
bothrenatarreflesand veinsand
the rliacvesselson bothsjdes.ll alsoprovides
accesstothe thirdandfourih
 g
4 rhe croshLoparolomy

parts of the duodenumano the

superiormesenteric vessels lt is
an awesome exposure we
stfongly recommend that You
carefullysiudy, understand'and
memorizeii becauseil is ihe key
to approaching someof the most
difficultabdominaliniuries.

The maior Pitiall with tight-

sided medialvisceralrotatronrs
injuryto ihe SMV at ihe root ol
the mesentery. Once Youdetach
the fight colon from its
peritoneal attachnreni,ii is
hangingbY its mesentetyaone.
An inadvertentPull will avulse
the dght colic vein off the SMV
resuliingin unexPected bleedlng
from the root of the mesenterY

fromCBDto ligamentof Treitz

maneuver:
TheCattell-Braasch

Selecting an oPetative Profile

for your
Now it is time to decidewhich operaiivepfoflleis appfopriale
repalrot danrageconirol(Chaptef1)'
paiientrde{initive

Iniury PatternsIndicatingthe Need for Bail Out

Combinedmajorvascularand hollowvisceralinjuries
'surgicalsoul' (Chaptet8)
Penettatinginjuryto the
High-grade Iiverinjury
Pelviclraciurewitf an e{pardrngpeivicl^e-aloma
lnjuriesrequiringsurgetyin othercavities(chest'head' neck]
E ,o, *",rr rn. orr& croftol Troumo
su.ger1,

Temporary abdominal closure

*rh:]: "i:[iF:';Hig:":T:fl;,
:::l?"5ffi
:'ilr
*"";;.;;il;"i
;f""ilffH:ff ;
Jiil:i,iliti"'
"i::;:i;:::'
contain
andprotect
theuo*"r*t*, t"iplilfiI--inJlfii

liJij:i:-;,":;;
::i'f:":it!.i,qii"i,:"_'ii"*r#:,::ft :t:
provtdesa meansfof collectingjnira-abdomi
creaies
a physicar
banier
beti,een j:l,i#:ijT:iii:i!;jl
ffiJfl
mass.This barrierpreventsadhesion
formatiofbeiween,f," l"*",1"j
ihe windowof opporiunity
ro, a.riniiv"
f.#"i:,:JI** "",ry

The vacuum pack is

essentialtya sandwich.
The first layer is a wide
polyethylenesheei ihat
you spread over the
abdominal viscera and
carefullytuck betweenthe
bowel and the abdominal
wall. Pui two surgjcai
towels over it, placed
securely beneath ihe
abdominal wall on all
srdes. This is the middle
rayerot the sandwichafd
iis pufpose is to absorb
 g
4 Thecroih toporoiomy

Now, Placeiwo siliconedrarnson

the towels and bring them oui
ihrough separate stab incisions
Coverthe wound with a wide sienle
polyest€r drape, comPleting .lhe
upper layer o{ lhe sandwrcn'
Connect the suctiontubing to a Y_
connector,then to a suclion source,

Occasionallywe sull use a soti

empty intravenousfluid bag fof
iemporary abdominal closure The

bag is unfolded bY
cutiing the seam and
then sterilized. We
suiureil to the skinalong
the edge of the wound
with a running heavy
monofilamenl sulufe,
preservingthe fascialor
the definitive closufe
This technique is more
tima-consuming than ihe
vacuumpackbut provdes
inexpensive,alraumatic
containmentof the abd_

akeady know about

There isn t much we can tell you thal you don'l
The correcttechnque
definitiveclosureof a midlinelapatotomyincision
Jrutino Uiqoire"c'ote rog€thFr, withoLitersronWe do a tass closure
sutJ'F'beoirnrrgai both
'",i i"v"",",i" ns . .-i19 heavymo'rofi'?mert
tn" i""i"i." and workingtoward the middle The cardinalsin s
""a" "t distended
tension lf you siruggle lo contain bulging or
"i"""* ""0",
uo*"t, ,f'" outi"n, f" ;uch betler off with temporaryclosure l/lakea
"iff
 4 rorrrn,*^.
_ ,* 44
8 CroltoI
i,outo Surger/

iihtil*r,",31
il'r".ffi
:,T:iT,,H,",:
THE KEY
POINTS
) EnterihebelJywjththfeesweeps
'--- ''ofi'n" nn^
oneeducated
finger
) siay awayfrom "nd
ord
"""r".
) Evisceraie
ihe boweteariy.
) In blunttrauma,
beginwithempirical
packrng.
) In penehating
trauma,eviscerate
andt" t"r thebleede'
) Exprorerhesupram""""",::*
,;,;
) Keepretroperitone",",r,:.;;,.,r;":::;J-*-.
) An expandingceniral
hemaiomadoes
t""""
) Feerrhemuscres
o,,r" ;";";;*,
,:";.
) Do a rjght-sided
medialvisceralrotatjon
in threestages.
) The Caiiell_Braasch
maneuverifrom
CE
) conian
andprorec,,,,"
;;:; ;; ;;,:";ffi_:"_"
 ChaPter5
Fixins Tubes:TheHollow Organs

lhal I saVshouldbearlhe apPeanncP of

Andif anvthing book
)-",'"r17ii'rt?r*u, let ie publiclycont'ess that Ihi5
''rigiroi 1r"* a sonooful
li"i""riti, coniemPlalionof the 'nonv
,nort ,nirn I ha;e myselfconmitted
- Harold Burlows, CBE
Erlalls o/S /ge'Y'2nd ldition'
London' Bailliere'Tindall arld Cox' 1925

'corrective experiences' in surglcal

One of the mosi remarkabLe
conference'as you
training comes during the morbidityand mortality
audience how you
relucta'ntlvrise io explain to an unsympaihetic
own expenencerno
overlook;dthatbulletholein the duodenumFromour
p"tti""r"rly convincing'so never get loo complacentwth
Jrir""
"or"a"
ihe injuredgut lt often hidessome nastytraps'

Immediate concerns
g n d c o n l a i l s p l l l a g eo ' ' 1 l e s t ' n a l
Y o u rl i ' s ' p r ' o ' i i e s a r e I o c o n l r o l o l e e d ' n a
mesertery does
-"*t ,i:"" ff'" **e' does 1oi bleed mJcn bJ'the
", vesselhas
lf the bleeding
retracted beiween lhe
leavesof the mesentery'
all you can see is an
expanding mesentenc
hemaioma.Raiher than
waste irme ttyrng Io
ideniify the bleeder,
simplyapply PressureIo
lhe area,We usuallyuse
either the assistants
hand or long sPonge_
holding{orcepsaPplleo
 TOPKNIfETheArt 8 Crofi of TrournoSurgery

to ihe injuredmesentericsegment,squeezingit gentlybetweenthe ringed

When the bleedinglacefationis close to the root of the mesentery

bewareof a irap. Neverjunrp in and bllndlyclampor oversewihe bleeder
becauseyou rnaydestroya superiofmesentericvesselorone of its maior
branches.A classicexampleis blunt avulsionof a proxinralbranchof ihe
SMV which can be the resultol a decelerationinjuryor iatrogenicirauma
lrom puilinghardon the mobilizedrightcolon.you encoufterbnskvenous
bleedingor a rapidlyexpandinghemalomaat the base of the mesentery
Blind clampingmay resultin a transectedand ligatedSIVV

The correct approach is to

insinuateyour hand behirdthe
mesentery and pinch the
bleeding area beiween thumb
and forefinger.This controlsthe
bleedrng. Now, carefullyoper
the serosa,preciselydefinethe
injury and fix it. With a bllnt
avulsroninjury,you will have to
fix a side-hole
in the SMV

Use soft bow6l clamps to

controlspillagefrom stomachor
bowelperforations. A holein the
stonrachor bowel can also be
temporarily whip-stltchedwlth
severalbjg bitesthat will control
mucosal bleeding. Pack a
bladderperforationfor lempofary

Bleedingfrom the root of the mesenteryis a trap

 TheHolowo'nt*
5 Fllng TLJbes: H

Missed injuries
will
wherecursoryinsPection
Pay specialatientionto five locaiions
oftenmissa holeln thegu:

c
tuophagogast Lbament or
Tleits

'nosl immeoiatecoiseorerces'
Mrssinga gastr;cPerfora'iorhas me
gLlt -lssing a I'ole
ci""" rL".qtomarhis tne 'nost vascLlarorgan ol tne
wthin a coLpleo{ hoursrac'nga
i""""- t", *if' be bacl in ll^eoR Much like a
Hil;;" ;" ; *atermelonfilledwith blood and clois
missed sastdc
;i;"J;; ;;; ;";"" the mosi problematicand easilv
or in ihe posterior wall near
iniuriesare locatedhigh on the lessercurve the
t"h"s'"ut"' bv dividins
or the stomach
;il
111'; ;;;t;" ""u' greatercurve
o""t."ofi. o."*rt. Ope; the lessersacwidelyand lifi ihe
wall'
;p to havea good look at the entirePosierior
 TOPKNIFE
TheAri & Croft of TroumoSurgery

ln additionto a very meiiculousexplorationroutine(Chapter4),

two
saleguardshelpyou to avoidmissinga hiddenjnjuryto the Gl ?aci:

1. Reconstructthe trajectoryof the woundingagent.Thrstmjectory

must
oe trnearand makesense.Bultetsand knifebtadesdo noi disappear
inio thin air on/y to feappearout of nowherein anotherpart of the
abdomen.Youmusl be able to connectthe dots. Whenthe trajectory
oi ihe wounding missileis unclear or does not make sense, you
probablyare missrngan injury.
2. Be concernedwhen findingan odd nlnrber of holesin ihe gut.
Tangeniialwounds certainlyoccur, and occasionally a mis;ile
pedoratesonly one wall, but this is uncommon.Therefore,
an odd
n!mber of holesshouldprompiyou to re-evaluate the areain search
ol a missedpedoraiion.The oniy exceptionis a singlestab woundto
the anteriorgastncwa I, which is relativelycomrnon.

When examiningthe colon,it paysto be relen|esslyparanoid.Because

nruch of the colon is reiroperitonealor covered with omentum and
pericolicfat, missinga smallcolonicperforaiionis easierthan yoLr
ihiik.
Do not leaveanysubserosalhematomaon ihe colon,no maiierhow smali
and rnnocent-looking, without unroofing it by opening the overlying
peritoneunr.Veryoften,this seeminglylnnocentsuperficialsiaininghides
a perforation.lf the wo!nding agentpassedcloseto the rightor left coton,
mobilizeit and look carefullyat ihe posteriorwat.

The ureter,1oo,cafriesa high rateof missedifjuries.Whenevera bullei

irajeciorypassesafywhereneara ureier,nrobilizethe re evaniside of the
colon,identifythe ureter,and irace ii proximallyand drstallyio ensureit is
intact.Iniravenousmethyleneblue dye helpsidentifya ureteralinjurythat
rs not rmmedaielyobvlous.

Bullettraiectoriesare linearand must makesense

 TubesTheHolowOrgo's n
5 Fr,lng

Choosing a repail technique

repairIhe ;nlutle5choosean ooeraliveprof e
Now that yoJ are 'eaoy to

r:r*il 3:l
:"1i1*:::':il"d1," ::ffilll
J:'l
::1"x1;;,:';li
';"::,*:;' ":"'il;"'
:i;"'i;
;r;:*ru:x'i:!J:,'il""i:'" YoLdon\ l've Io do a ro-mal'esecton
;"-;;'iai";;i;o;-"sorLi'ons
andreconstruction to preventspillage'

Damage control fot the bowel

wayto preventspillage{roma eeforillon-(11-d-l:

Themost€xpeditious
is to *t*t
rapidly
uchi"velemostusjsat tne sametime) ' ' ]:,i:'iS-:^:19-:
t"a' -taP el Whel operat ng
less common y a lr'.,
,ayercontin,oLs stilcl' or'
;';;;;; areofte"ll|]*"1-1""^llllill
;;",;;.;''however,there
phvs'orosv,
ard the parent's ard-assourarFd
ffi.;:1."ti;; ;;
p€rcn
i": i" il"""i",r.-il rooarieri,y up.hor" i-,::]ill"]lljllt",i
tle'e ar€ tnFmostcommon'Y
q;:c^ ard ef€cllvFspi"ageconLrolso uton
used opiions:

a Bowel interruptlon oY
stapling across wfln a
linearsiaplerPfoxmalano
distal to the Perforated
segment, or ligating ihe
bowel usinga cotionlaPe
wiihoutreseci|on
a Bowel resection without
anasiomosis is a good
solutionif ihe injuryinvolves
a bleeding mesentery ll
you have to resect a
considerable lengih ol
bowel in a Patrenl /n
exfremis, Your qulcKesl
optionis to sequentially fire
a series of linear cutting
siaPLerswith vascular
E ,o, *"n, rn" o,t & crcrft
oi Troumo
suroerv

loadsacrossthe mesenterycloseio the bowelwall. lf residual

oozing
f.o- rhe craole.haeoersists, raordlyunderrun,twrtr a cont,r-oui
monottamenlstilch
a Stapled partial gastlc resection without reconstruction for
a
devastairnggastric inluryis a third opiion. This staptedemergefcy
gastreciomyis a stagedprocedure- wiih resectionduring
the initial
bail oli laparotomyand reconstruciion at laier reoperation.

During a bail oui laparotomy,avoid externalstomas,if possib/e.The

abdominalwall swel/sup postoperatively,and ihe stomaoften retractsor
becomesischemic.By cfeatiig a stoma you afe also makifg definiiive
abdominalclosuremoredifficuli.

Youcan conholspillageffom the injuredgut withoutresection

Ulological damagecontrol

Ur ne spillageintoihe periionealcavty caffiesa much lowershort_term

nsk of infectionthan intesiinalspillage.If time is criticaland you need
to
get out of the abdomen, tle off a transected ureter and plan
a
percutaneousnephrostomyif the patjentsurvives.lf you haveno time
to
fepair an injuredbladder,just pack ii and rety on a Fotey catheterfor
drarnage- a suboptirnalbul accepiablesolutionif extremecircu..stances.

It you have a few minuies,intubatethe tnjuredor transectedureter

proximallyusing any availableihin caiheter (such as a pediatricfeeding
tube). Secure ihe ureterto ihis drajn with a tie and exierlorizeihe drai;
throughthe abdominalwall. Leavethe distalureteralone.It will not leak.

The biggestm stakeyo! can make with a ureteralinjuryls io mobilize

and dissectoui the ureterin an attempito betterdefinethe injury.you will
only jeopardizethe blood suppty of the njured ureter and make
subsequefireconstructron more difficult.lf you afe noi goingto repairit,
lust divertthe urineand don t fjddlewith the Lrreter.
 HollowOrgons f
5 FixingTubes:The

runningstitch lt doesn'thaveto be
Close a bladderiniurywith a quick layerwrll
r."'"ni"1l","a if you are pressed{or time: a single
iay loi be
"^^ ' "t.a-*pair tne besl oot;on' sLture closure
" ;." Wfit" a'wavs oLcasionsvou'naveecr
L"j o,"r"'ir u u"'v,"tn"deleclOnrhose'are theopenbladder
,ffi.ri lt *tr#r"J roih uretersandiightlvpacking
{orhemosiasis

i-,"i*n" it damagecontroloptionfor the ureter

"n "t""tt.nt

Def inifive lePair techniques

The stofiach arrd distal esophagr'rs

slaoler'On ra"eocca"'ons
Reoairqaslt'cperforationsJs:nga 5ut'i'e or
panialgasirecto-y
massrveo;skJcl:on ol the stomauhrcqJiresd

difficultto visualizeand
The cardia is ihe pari of ihe stomachmost
these problematrcInlurles
repair,especiallyin obese patients Approach
as
svstemarrcdly. Frrs',opirmireyourexposu-el- lh6 ncisonene'rdrng
fj, ," do ng urelJlwork?SnoJrdvouinseri
o"i"iUf"f ," r"'r'-Fi;ac1or
uP?Nen' mobilizethe EG
." ,lp* i""l i"u*t,irr lslhe patientiiltedhead
".
jlnction as il You wete gorng
to do a vagotomy We do
realizethis is rapidlYbecoming
a losi ad, but in this situationii
is the key maneuver' Take
down the left iriangular
ligamenioJ the liver,told uP
the left laierallob6, oPen the
posteriorPeritoneum overlYrng
the esophagus along the
'white llne,' and encirclethe
esophaguswlth Your nnger
This givesyou good accessIo
the injuri,.
 TOPKNIFE
]he Art & Croft of TroumoSurgery

Someijmesyou have to develop a creativetechnicalsolutionfor a

proximaJgastricinjury.Jfyou cannotroli ihe distalesophagusand cardra
io exposethe injLrrybecauseit is posterior,open the anteriorwall of the
stomachlongitudinally near ihe cardia,ihen jderiify and repair ihe hjgh
postenorperforationfrom withinih€ siomach.

Injuriesto the disial (abdominat)esophagusrequire the same

mobilization of the EG junctionand care{u definitionofthe lnjury.lfyouare
operatingjn damagecontrol mode and there is no trme for meiicuous
dissectionard repair,inserta largesuctior drainintoihe open esophagus
and bring it out thfoughthe abdomifalwall, creatinga controlledlistua.
This effectivetemporarysoution eaves ihe door open for later

We repair a slmple lacerationof the distal esophagususing a single

layersutureafter carefuldebridemeniof the pedoration,and we always
drainthe area.You can use the cardiaof the sromacnas a serosatpalch
(Thals paich) to buttressthe repair.Very rarely,you wlll encolnter a
devastaiinglnjury that has destroyedthe EG juncrion and requires
resectionof the distal esophagusand proximalstomach - a proxrmal
gastreciomy. Thesepatientstypicallyhavemultipleassocratedinjuriesand
needa rapidbailoui solution.Transeciihe siomachacrossthe body using
a lrnearstapler,preservlngas much drstalstomachas posslble.Lift ihe
proxmal part of the inluredstomachand mob lize lt alongthe lesserand
grearercurves atl the way up to ihe esophagus.Divide the nrobillzed
esophagusas low as possjbieand removeihe destroyedpart of ihe
proximalstomach.Securethe open esophagealstumpto the diaphragm
to preventretractionintothe chest,and inserta closedsucliondrain inio
the lumen.This danrageconlrol solutionleavesthe pateni with a stapled
distalgasiric remnantand a dfainedopen esophagealstump.

Accessproximalgashicinjuriesby mobilizingthe EGiunction

 TheHolow O'gt*
5 FlxlngTLJbesr E|

The small bowel

Beforerepairing a holein thesmallboweL makesurethe edgesol lhe

wall is bluishor
p"*or"tion ur" hJafthyand oozingnicely-If ihe bowel
important wiih high-velocty
iraumatizeo, debrideit. This is especially
*1"t" tissuedamagearoundthe holecan extensive
be
"rnlnoi*ou"a"
Lornrnon dictatesrepairoJ bowel perforations in a transverse
""n"" io avoid
*ti'"t tf,"" fongitudlnally, narrowingthe lumenJoining
o--ri""i"tl.n,
i"'o * rlsave lrme Lrouore
you a,rd Hoes
" "nsle-'acerar'or 'o fi^ CatefJrly
ln'*" n'","t"n" bo,Jeror the bowe can oe t'ic\y
".L"".iia".
mobilize theadiacent mesenteryto seeihe entiredefectclearlybeforeyou
beginsewing.

wiihiniudes io themostproximal jejunalsegment

Expectsomedifficulty
r'eitz T;e kev is io ihe
mobilize ligament andfree
**'iJii" o"t""
"f Rarely'you may haveio do a completeCattell'
if'"-frorinra"ppnrrrl
portionol the
era.""L man"uuel.(Chapter4) to get to the foudh
duodenum andiis transitlon inlothe proximaljejunum

Repai'IhebowelLsi,rgILe tFchnroLre yoL a e -osl co-lortablewi'h'

O_e ol u- p'e{ersto useo si_ge taye'corriruous st tc,rrormoslGl sul'r'e
prefers a double layer
lines (includingthe stomach)'while the other -esLhng
i,r a.l irvered
techn'qLe.Bot,l a'p sale 'r perfo'meocorr"uJv
-ension lf yoL n^us'do a bowe'
*ell.vasculanzeo sLLUreire will^oLl
of sulurelLnes
fesection,preservebowellengthand minimizethe number
rhe befte'
Tnelpwe'suiLrelinesyoucreale

bowellenglhand keepsuturelinesto a minimum

Preserue

Colon tt til rcctum

with a simplesr'riure_jusl do ii No
lf vou can closethe 6olonLacetaiion
you ffom doLnga
amo;nt of peitoneal contaminationshould dissuade
colonlc segment
straightfoMardprinraryrepair' Blt what if ihe injured
mLrstbe resecied?
 TOPKNITETheAd & Croft oi TroumoSLrrgery

For a right-sidedor transversecoton injury,the answeris simpte:do a

right coiectomyafd join the terminalileumto the iransversecolon. This
sate anastomosisis unlikelyto cause you gref. The questionbecomes
moreinteresiing(andmorecontroversial) in the leftcolon.your optionsare
io do a colocolostomyor to closethe drstalcolon as a Harlman,spouch,
bringingout the proximalsegmentas a colostomy.An extendedrighi
colectomyand rleocolostomy in ihe descendingcolor is a va id alternative,
bul t is se,domLsedin -raL-a becaJseI is ttme-consum n9.

In recent years, resectingand joining ihe unpreparedleft co/on has

becomea iashionableopiion.I\,4any surgeonsialk aboutii;fewer do it, and
some havehad occasionto regrei it. We belongto the lafiergroup. Our
preferencefor extensiveIeftcolondamageis resectionand colostomy. We
mayoccasionally do a co ocolostomyfor an isolatedcoloninjuryin ayoung
stablepaiieniwho can toleraiea ieak.We would not evencontemoaie lt
i,ra oal,e,rt
who ha- sJsr€rleomassiveprysotogiuarrsJlt,rs eldelv dnd
f.ai,.of Lnde.wentoihe. -epairstl-atmav lea\. A case in ponl i; the
exposive combinationof left colon and left kidneyrepairc,where a leak
from one suturelineputs the olher repairln immediatejeopardy.

lManysurgeonstalk aboutcolocolostomy
for lrauma;fewerdo it

Deal with an niuryto the intrapeftonealrectumexactlyas you would

handle a peforaied left colon. ManagementoJ trauma to the
extfaperilonearecium used io be an elaborateritualihat lnclLrdediotal
diversion,repairof the injury,washoutof the distatreciatstump,and pre-
sacraldrainage.The currentapproachis much slmpler:

1 . Tryto identifyihe injuryusinga rigid procioscope.Repairit only if tt is

easrlyaccesstble.lf you suspeci a rectal rnjurybut canrot prove it,
perlorm an enrpiricalfecal diversion.A temporarycolostomyis a
nuisanceia missedlower rectalinjurycan be iatat.
2. Do a slgmoid loop colostomy.When properlyconstruciedat skin-
level,ii is totaly diverilng.Somesurgeonsuse a linearstaplerto ctose
the coionimmediately distaitothe colostomy,oryou can sjrnplyiie the
sigmoidwiih a heavypolypropylene sutureand anchorthe stitch to
ihe fascia.
 g
Ihe Holow Orgo"s
5 FjxlngTLrbes:

3, Don'i irrigalethe rectal stump don't insert a Presacraldraln'

Neitheris necessary'

6IJ t"*t
tn"-"*
tn" awayfromextrapetonealrecialinluries
"tr""t

Bladderandwetet inities
word: DON'TLWhen
Here, we can summarizeour advice in a single
of an injuredbladder
oos"ifL. ast u urofogi"tto performdefiniiiverepair
las a beitergrasp of the varioustechnicalopiions
lr ureie. The ,-rrotogist
f]o* to fest one for a specificsituationFurthermote'the
""J "loo*in"manageany complicaiionsand underiakelong'term
ufolooistwill also
pre even wrlh
folrowl-rp.Wheneve. pocsibe. we aol^ereIo tnis onnc
Jto'ogst is nol
straiohtlo'wardilltapethoneal badde' njuries li a
avail;ble,damageconirol is alwaysa soundoption

THE KEY POINTS

) Bleedingfrom the root of the mesentefyis a trap

) Bullettraiectoriesare linearand must makesense

reseciion
) You can controlspillageffom ihe irjured gui wilhoui

> Drainageis an excellentdamageconttoloplionfor the ureier'

junctron'
) Accessproximalgastricinjuriesby mobilizingthe EG

) Preservebowel lengthand keep suturelineslo a minimum'

for trauma;fewer do it'

Manysurgeonsialk aboutcolocolostomy
>
rectalinjuries'
Dlvedthe fecal stteamawayfrom extfaperitoneal
)
 P ,o, *n,rrrn. on & cfofrofTroumo
sursery

a.npoa,tt aa$
{ J "49
* ^"- ^B carry'u'67-
- r^'v')
' /1,-0 \r,

----.-\

?'.ct<1 t{*: o .L\}-,**G4-.

I
#-

&r'- (1fnt
t,.t".tzl-}\ g,tt 4
o- 'z r*7*l< -
&,t.-s-x-
uJ^rr^d r-*.4

V
 Chapter 6

The Iniured Liver: Ninja Master

No battle plafl s roioesthefirst fiae

fiill tes oI cofttttct Toith the eflefi!'

- Field Marshal Helmuth von Moltke

liver is the Ninja

l{ traumasurgeryis a contactspori, lhe badly iniuted
you come lace_lo_
Master:a vicious,cunningand lethaladversafyWhen
bleedlngllver'gLanceai ihe OR clock and thenatthe
facewith a massively
products into a raprd
anesthesiologyteam franticallypouring blood
and roughly8-10
;nt,rsiond"UJe you huvea windowof aboul 20 minutes
all Take much longer'losemore
unitsof bLoodio slop the bleedlngThat's
ii"oO, ot."t" an errorln iudgrientor iechnique' and ihe NinjaN4aster
winsagain

Obtain temporary control of bleeding

of th€ lver
Once insidethe abdomen,quicklylook al the undersurface
boih sides ol
and swipe your hand over ihe superiorhepaiicsLldaceon
youwillsee or leel
ihe falciiormllgamenilflhete ls a signiflcantliverinjury'
- don tl An obvious
ii. At ihis point ii is temptingto start fixingthe iniury
of hemorrhage and noi
lwer injury is often jusl one of severalsources
to zoom
necessarily the mosi importantone Resistyour naturaltendency
rapidlyassessingthe
ln on the bleedingliveras yout pdme iarget befofe
rest of the abdomen

The three
YourfLrstprioritywiih a bleedingliler is to stop ihe bleeding
temporary
ootions {of ter.porary control are manual compression'
option is useful for specifrc
packing,and ihe Pringle maneuver Each
operativecLrcumslances
 TOPKNIFE
TheArt & Croft of TroLrmo
Surgery

a Have your asslstantreach across ihe operaUngta6te and nanualy

compress the injured lobe behir'eenthe palms of both hands, an
excerrent way to gajn temporaryconlrol of a badlyshaiieredlobe. li
also allowsyou to beginhepaticmobilization aroundthe compressing
hands.
) Tenporatypackingts a good rnriralmove,especrallytf you are not
sure if the liveris the majorsourceof bteedtng.Rapidtycompressthe
lnjufed lobe in a sandwrchof laparotomypacks placed above and
below it (Chapter2). You wit return shorilyfor a ctoser took and
definitivehemostasis.
a li the iver is bleeding
despitetemporarypacking,
consider inflow occlusion
of ihe portaltriad, the well-
known Pringlemaneuver.
Pokea ho/ein afr avasculaf
portion of the lesser
omentumto ihe left of the
porial tfiad, inseri an
educatedftnger into the
essersac, and gentlypinch
the portal tlad between
th!mb and Jorefinger. lf the
maneuveris workingand
bleedrng stops, replace
your ingers with a large
aortc vascuarclamp,a Rummettourniquet, or (if noneof these s
immediaielyavailable)a soft non-crushingbowel clamp. Note ihe
tme. Nobodyknows for sure how lofg the porial triad of a trauma
paiientcan remainclampedbeforeischemicdamageoccurs,but you
have at least 30-45 mlnutes,probablymore. Rer.oveihe clamp as
quicklyas you can.

Sometimesyourtemporaryhemostaiicmaneuverfails and the bleeding

continues.Barring a techncal error (such as neffectivepacking or an
 Lverrinl" v"'t"' Il
6Ihelnjured

thereare ihree posslbe reasons

incorrectlyperformedPrlnglemaneuver),
Jorongoinghemorfhage:
'ntlowocclus:on
a Packsoo 1ol conlrolane'al b eeoilg Youreeo
despite inilow occlusron'
a lf the bleedinglrom lhe liver looks aderial
Try supracellac
ihe hepaiic ;ery may have an anomalousorigin
aodicclamPing
ihe liver'you
a lf dark bloodi; gushingfrom the deep recessesbehind
you aren'i sufe' ask
are aeatlng*iih'a rei;hepatic venousinjury lf
ilJ disconnect
to momentatily the paiientfrom ih€
"n""tf'"""iofosi"t your s'rspicron is uonf'r ed and yoJ
1 ventlalo- l{ tne b,eeoingabares'
- panentare i; dt;FlroLb'€ lncise lhe lalc;for- ligameni'
,no
"or.
g"-'i, *i'i a"-p ald oushs"rirvPosr"rio''' ''i,,:1 *::
" il:t: bleedlngwn |e
ilts tne rv"r ba'kward end maylemporarily"ortrolil'e
yol.rcolsioer your oprio,rsand orgarrTeyoJr attaLk

pack'or clamp
Controlthelivertemporarilyuginghand,

Mobilize the iniured lobe

Unless ihe hepatic
laceraiionis Peripheraland
anterior, youcannotassessor
fepair it until You have
deliveredthe injuredlobe to
the midline, much like the
injuredspleen.To mobilizethe
left lobe, dividethe iaLciform
ligamenibetweenclamPsand
then releasert all the way uP
to ihe diaPhragm,exposLng
the areolartissueof ihe bare
area of the liver Then divide
the left triangular ligament
and conUnuethe incisioninio
the anterior and Posterior
coronaryligamenis Beware
of the Phrenicvein that is
very closeto your scissors
 TOPKNIFE
TheArl & CroftofTroumoSurgery

S r.ilarly,puttlngyour hand
behrnd the right iobe and
rotating jt medialjystreiches
the right triangular ligament
and allows you to divide it
safely.Continuethe mobil
izatiof by releasing the
anteror corofary ligament
(takingcare not to inlure the
lver capsule or the right
draphragm)and then the
posterior coronary ligameni.
Your goal is to deliver the
eftire rrghilobeio the midline.

Be liberalwithyour mobilization,
but atso be carefulithe hepaticverns
and IVC are wa,t.rgtor a carele5smove,ano tre smal,acce;so-yve 1s
enieringthe IVC below the right hepaticvein are easrlyavulsedwith a

Mobilizethe injured lobe to deal with it face-to-face

Here,a deadlypitfallawaiisyou. N4assivegushesof dark blood comrng

througha deep iaceraton n the liveror from behindit ik_"lyrepresenian
njury to ihe retrohepaticveins.Mobiizingthe liver in ihis situationis a
recipe for disaster You wil lose containment,and the patient wil
exsanguinatefrom uncontrolledvenous hemorrhagebefore you even
realizeyourmistake.So, ifyou haveanysuspicionof a retrohepaticvenous
injury,don t mobilizethe liver

Small problem or BIG TROUBLE?

Nowheres thedislinction betweensmallprobtems andBtc TROUBLE

(Chapter2) more usefulthaf in hepaticirauma.Small problemsare liver
Inlunesthat you can fix wiih a direct, srmplemaneuver:the diathermy,a
liverstiich,or a loca hemostaticagent.The injuryis accessibleand bLood
loss is noi dramatic.Most liverinjuriesbelongin this category.
 g
6 rhe lnturedLrver'NinloMoster

iniurywithmassive
is a high-gtade bloodloss'andyou
BIGTROUBLE
*"'i" it.i"""ia*g"t i lJsingyourpatientThedecisionwhetherlhe
ii,y i" ptoSL. or BIGTROUBLE is the kevstategicdecisionin
" "."rr
lrauma
hepatrc
is not
injuriesdirectlylf a superficialaceration
Dealwith low_grade
pressure for a lew
of"eJlnq,f"au" it lrone l{ ihereis slowoozing,direct
stopsthe bleedingYour hemostatic effods should be
t""i."".U""
proportionaltothemagnitude of theinjury(Chapier2)

With deePerlaceraiions'
have your assistant Pinch
ihe edges of the laceration,
turn the cautery to KILL,
and blast the faw bleeding
sudace, focusing on the
disruPied edges of the
hepaiic caPsule APP|Yihe
cautery to a metal sucker
lip to achieve a wider
effect.Use an Argon Beam
Coagulaior,i{ available,to
thoroughlYbarbequeihe
raw surface. Use a toplcal
hemostailcagent You are
Jamiliarwith from electve
tJ-'
surgery.
,- t
holo you need a
Nevi, consrderhepdlorrhap'lyFor yoLr sJlLres Io
,"""onufty int""t ani a moreor less Linearlacefalionthat can be
""p*te with 0
sidelo_side We typlcallysuiure hepaticlaceraiions
"_o-otlt"t"a row of horizonial maitress
.iiornl" on utrnt-iipLurgeneedle,cfeatlnga
" parenchyma'ano
sutures.The chromicsutureslidesthroughthe hepatlc
good bite ot irssue
ihe laroecurvedneedleenablesyou to obtaina
 TOPKNTFE
TheAri & Croft of TroumoSurgery

WrrhBlc TROUBLE, youare ope.aring ..l damagecontrotrnode.Ihe

,
Key lo sLccess ts yorr ability-o srop the ooFraltol a1o o.ga'lizeyoLl
attack on the injury rather than get canied away and attempi
h;rorc
maneuverson an exsanguinating patient {Chapter 2). The rest of thig
chapterdescribesihe techniqueswe have found most lseful in
baifles
wilh hepaticBlc TROUBLE.

Decideif yousre dealingwitha smallproblemor BIGTROUBLE

"Packing plus,,

Packingis the techniqueyou will use most commonJy for a high-grade

|ver injury.lf you have packedthe liver early as a temporaryhemostatic
maneuverand the bleedinghas stopped,you haveachievedhomostasis.
Removingpacksat this point is a mistake.

When you cannot be sure thai you have completehemostasiswth

packing,especiallyjf you hadto removethe packsfor bleedingbui did
noi
find any discrete arte al bleedefs, considetpacking p/us - imrnediate
postoperativeangiographywith selectiveembolizalionas a hemostatic
adjunct. Thjs is a risky undertakingin a critical patient and involves
mobilizingfesourcesthai may not be avajlableto you. However,if it is a
realistcoptionai yourinstltution,
selectiveembolization
of arterialbleeders
deep within the liver can be lfesaving. lf your OR has rntraoperative
angiographiccapabilities,the decision is easy, and embotizationis
possibiewithouimovingthe paiient.lt is crucialio makethe decisionearly.
Decidethat you are going fof angiographywhile you ar6 repackingthe
liver,noi thfee hourclaler.

Keep in mind that angiographjcemboljzationis an adluncito effeciive

packing,not a substitutefor sloppyhemostasis.lf you didn t packthe ljvef
properly,angiogfaphicembolization will not saveyour patient.

Considerangiographic
embolization
as an adjunctto packing
 6 rhe Injured Live( Ninjo Moster
bl"'t 'ti1
o c \ ' t t ' / n "c' ' ; ' ^
Deepliver sutures L+7 ;'f*J(r. '
Theycausenecrosis of tissue
Deeplivelsulureshavea badreputation 'liver{ever'from
lnclorpJratea in the stitch,predisposing to inlectionor
ntec,iot Do,.t lel rhs bdd teoutalior rob vol o{ an
;;;;ir*l i{ donI
#:# ;;p- ,",' bahrewitl^tnp\rniaMaster'espec:aryvou
" oui
;;".;;;;*";" wlth the injuredliveror needa rapid bail
O f,* O"t'*, *ith somehepaticnecrosis is farbetierihana dead
""ili'"".

aust nave a,l i,rlacl caosule to

Wnen olac nq deep hve- "LLures you
as r vou are tyr'lg a sJrure
hol em Wh; ryirg righter ver)/ carelully
parenchyrna
ir,-r,*gi oft,go""i [utter' Look for blanchingof the liver
t:qhl Cl"oosea suru'e
u."",*,n. =ut,-r".w\icl'siqnf:esthe sulLrPis
spec:fc anatomiuc'rcJmstdnces:
r""a"r"t'"" Ihat is best lof lhe
il;ffi i;' so,neti,nes a {isufeof B' or a simple-
uerti"atlmattress'
buttfessRegardlessor
iffii'""i'tnt""gf', withor wlthouianomental of hepatictissue'
il** io obtaina good purchase
configuration,
"o* to the surfaceof lhe lrverand
in'" n""J" .""t u,iu"t" tove perpendicular

posioperativebleeding As the
A irap with deep liver suluresis early
cJt lh'oLgh the ede'natoJs
rnureo l,ver swells the s'ilures mdy
and rebleedilq'
pu,"n"t'yt" *'tn 'o"" ot Lnehemoslaticef{ecl

Deepliversuturesare not a crime

Hepatotomy with selectivevascular ligation

bleedinglrom deep in the lrvet'
This is a usefullechniqueto contfol
surgeon When you s€e anenal
especiallyif you are an experienced to close a
f'"L.rrf'"g" ft.. a deep laceraiion'ratherthan irying
".*tnoplenit w'derard so in l^o nrsLirorrFenddena e"al
;;;; ';"";*"
lo findsarerv
goto tneheartot danger
iiJo"'" l"
"""'"o,*
E roa ^",rr rn. on & croftoi Troumo
suroerv

With a pringle maneuverin

place,inciseihe hepaticcapsute
wfh the cauteryio extendthe
Iaceration,Then, open the
parenchymaIn the directionof
the injuryusingfingerffaciure(or
a bluntmetalinstrLrment).
As you
go deeper into the liver,gentiy
rnserta pair of narrow Deaver
relractorstnto ihe Jaceration to
facilitate exposure. L,sing this
technique,the liver parcnchyma
orsrntegrates beh,veen your
fingers while ihe ductal
structuresremaininiactand carl
be controlled (with ligatufes,
sutures or rnetal hemostatic
clips)and divided,enabJing you
to widenthe gap a1o go daeper.We preler to 5uurer.gate
all sign:f.cani
orFedersbeL€LsesLtu.ergrures do nor shpwher you
conr,nuewor^rng
In rne area.tt you use ]relal ne-roslal,c
c,ips.apotyrwo ul,pslo each
ductal structure (doublectipping)to pfevenrstipping.
, Occasionaly,an
rnlured targe intralobarvein will require laiefal repair using
S:O
porypropylene.

HepaloromywJr selec-ivevascu'arligatiol is a near uoncepr.

b i tls
in the real worid is tess straightforwardthan the preceding
lfelrc.alron
description leadsyou to be/jeve.lt invotvessignificantongoingbtooa
toss]
: ll-:::*-nn ,a-,oeenc
,rrLrrroa malo.reparc
duct o. h la. vesser.LJceir onty afler you havFo.ga'rizeoyoLr
ailact and
wnen rne pdnent c esLscitatedand ca'r io,erateadoilior.t
olood loss. lf
you don t have-ucn expefiercewirhneparictrauma,
deep rivFrsutJres
can Ee a s mpteralternative,

Hepatotomy
withselective
ligationis easiersaidthandone
 g
6 TheInluredU'er: NinioMo'ter

The viable omental Pe'licle

On comple+lon and seleclvevascula'

ol ilngerf-acturehePatotomy
r;oJln. uo, are tefr w-itha considerable dead space Fillng it wrth
livetsuturewhere
^ o*o idea.Thesameappliesro a deep
"il""irtti* youachieve
*" r'relp hemostasrs ln fact whendealing
"'"""ili..""",".
*ii 'i" t*,"a ruer,rh" greate-omentum rsoneor vourbest{riends

rhegreateromentum ofl Ine [ansversecolon

lf voJ havetime,mobrize
chunk,typicallylromtherighiside'
aoniiie tuoauss tineSelecta healthy
the omentum towardthe
longitudinally greater
and-separate it by dividing
curve of the stomach.
Swing the mobilized
tongueof omenlumuP
into ihe iniured livet
and fix ii to ihe Lrver
capsule with sevefal
loosestitches.Another
option is slufling the
omentaltongueiightly
lnto the laceration,
{illinglhe space, and
then approximaiing the
lacerationlooselywlth
several liver stiiches
overthe omentalPack
Some surgeons use
omentum{or Packing
{rom within insieadof
laparoiomy Pads or
gauzerolls.

defecb with omentum

Filllargeparenchymal
 IOP KNIFETheAd & Croft of TroumoSurgery

Balloon tamponade

Whendealingwith a
through-and.ihrough
(transfixing)
lver injury,
whrchrnayoccasionally
Invoive both lobes,
renremberthe optionof
bailoontamponade- an
Ingenrousand easy
solutionto a very bad
problem.Thealternairve
is erlensjve iractotomy
to achieve direct
hemostasis.

lf the tract is wide (2cm in diameteror more),we use a Blakemoretube.

Insedthe iube intothe tractso thatthe gastricballoon,inflatedoutsidethe
exitwoundfrom the liver,will serveas an anchorto preventdrslodoement
of lle ruoe.Then genry ir,latFrhe esool^ageal oaloo,rr. the tait u-ril
bleedingstops.

lf the tract is ioo narrowor ioo shortfor a Blakemoretube,we improvise

a balloonlroma .ed .Lbbercarheterand a pe'rrosedrain.T,eofl onpend of
the drain with two heavysitk ties. Tie the otherend afoundihe catheter.
creaiinga sausage-shaped bal/oon.Checkthe balloonfor leaksbv iniectino
calinerlroughthe reo .Lbbercalhererard La-pirg f. ne'aevce,i
working,insertthe ballooninto the lract and brjng the oiher end of the
catheterout througha stab rncisionin the abdominalwall, as if it were a
drain.Inflatethe balloonandwatchbleedingstop as if by magic.Securethe
red rubbefcatheierio the skinand makesurethe end is ciamped.

Youcan safelybegin removingthe balloonat ihe bedsideafter 24-4g

hours.Firsi deflatethe device,but keep ii jn placefor 6-8 hours.lf ihere
is no clinicalevidenceof bleeding,
pulltheballoonoui likeyouwouldafv
olherdraif.

Balloontamponadeis a cool solutionfor a bad problem

 6 The LniuredLiver:Ninjo Mosler

Resectionaldebridement
bleeding
When a subslaniialpart of the hepaticlobe is desiroyedand
debridemeni Have your
orofusely,ihe mostexpedientopiionis reseclional
lhe non'injuredliverparenchyma around the
^"ai"t"ni n
"nuully"otpress o{ien your
area you wish to resect lf the lobe ls properly mobilized'
ihe injuredpart' minimizing
assiint wiLlbe able to completelyencircle
blood loss whlLeyou do the reseclon
thai
Turnthe cauterylo maximumand use it to de{inea lineof resectlon
Always
is immediatelyoutsidethe injuredarea in healthyhepatictissue
area where the vesselsate iniaci
resect imrneiiatelyoutsidethe injured
rh,s is ,he \ev
and have 1or rer;credi
"_j.=-jj!I:El_!jg]
maneuver of resectonaldebndemenl
'pinched corn bread' maneuver)and
Perform finger fracture (ihe
The slmplest
selective ligati;n along your chosen !ine of resection
o{ the left lobe along
lateraL
examplefoiuse of this techniqueis resection
to the left of the lalciformligament Some surgeons Llse
a llneimnrediately
ih s non_
a linearcuiting staplerwiih a vascularstaple load io faciliiate
anatomichePaticresection

Much like hepatotomyand seleclive vascular ligatlon' reseciional

Don'l
debridementtakes iime and involvesconslderableblood loss
Organze youf
aitempi it in a Patientrapidlydving on the operatlngtable
aliack and resuscitaieihe patientbeforeyou begrn

debridementin healthylivertissue
Performresectional

Othel techniques

The traLrmaliteratrrreis repleiewith manytechniquesthat resourcelul

suroeonshavedevelopedior dealingwilh bad liver injuries One example
'pita of absorbablemesh
is tie absorbablemeshwrap. By snuglyJittinga
elfectlve
arounda shatteredobe, ihe advocaiesof thistechniqueachieve
iamponade, avoidng lhe need for packing We find this technrque
c!mbersoraeand do noi use it,
 TOPKNIFE
TheAd & Croft of TroumoSurgery

Hepaiicarteryligationis siill meniionedin traumatextsas an effective

hemostatic_technique. Somesurgeonsuse ji for ongoingarterialbleeding
noi controlledby oiher means.We havenot usedthis iechniquein years.

How about drainirgthe inluredljver?This is a somewhatcontroversjal

iopic. One of us routinelydrainsall high-gradeliverifjuries usinga closed
suctiof drain,whilethe otheralmosineverdoes.

Rehohepaticvenousiniury
Gushingdark blood from a deep hote in the tiveror from behrndafd
around t usuallymeansan njuryto eitherthe retrohepaticIVC or hepatic
veins.Theseencountersare rare, brief, and brutal.[4or€ often ihan fot,
the resultrs of-tableexsanguination
and a veryfrustratedsurgeon.

The retrohepaticveins are ihe east accessiblevascularsiructuresin

the abdomen.You cannoi get to them and define the injuryunlessyou
somehowcontrolthe hemorhage.The classictechniqueto accomplish
this rs the atriocaval(Schrock)shunt,one o{ ihe ,,greattechnicalfeats,,of
traumasurgery.Youwillfind elegantlll!stralionsdeprctingihe techniquen
everymalortraumabook, bui not rn ihis one.Why? Becauseif real life il
very rarely works. In fact, even rn the most expeienced hands, the
atriocavalshunthas drsmalresults.

lrstead of engagng in Jutle heroics,use common sense. The

retrohepalicvetnsare a lowpressure sysiem amenableto containment
and tamponade.Yourbest move,therefore,is to containthe injlry, not try
and fix it. A retrohepaticvenousinjurybleedsfreelyonly if one or more of
its containmertstructuresis disr!pted. These structuresare ihe
suspensoryltgameftsof ihe liver (markirgihe bordersof the bare area),
ihe rightdiaphragm,and the liv6ritsetf.

Yourrealisticopliofs for dealingwith a retrohepaticvenousinjuryare:

a Leavea containedretrohepatichematomaalone.Don t mobiljzethe

liver and don I try to explorethe hematoma.Just move on io other
injuries{andcountyourbtessings).
 6 The lnjured Liver:N njo Moner

parenchyma'
a l{ dark bloodis gushingout from a deep holein the liver
pLugthe hole. Pack ii with a laparotomypad, viable omentum'or
ballooniamponade.Whateverii takes- iusi plug the hole'
'Pandora'sBox (Chapter10) A hole in the right
a Don't open
diaphfagm bleeding inlo the chest in a patieni wlth penetratrng
thoracoabdominaltrauma can hide a retrohepatlcvenous rnlury
Simplyclosethe hole and don t mobilizethe hver'
a When bleedingemanatesffom behindthe liver,iry to determineif the
sourceis belowor behindthe liver.Injuriesto ihe IVC belowthe liver
(ihe pararenaland suprarenalsegments)afe accessibleto direct
repair.lt's difficult,but can be done.
a lf the suspensoryligamenisof the liver are distupied, your best
chanceto controlthe bleedingis packingihe areaquicklyand tightly'
Wiih limted disrupiion of the ligamenis,you may be able io re_
esiablishconlainmentwith packing.Wiih massivedisruplion,often
associatedwith a high-gradeliverinjurythe battleis usuallylosl even
beforeyou siad Packrng.

Should you even consideran atriocavalshunt? lt may be a realistic

option,but only under very speclflccircumstances'You need two teams
of experiencedsurgeonswho can work simullaneously in the abdomen
and chest,the necessaryequipmenimust be and
available, bleedingmust
be temporarllyconirolledwhileihe effod is organized

The technque entailsa medan sternotomy, sutureIn lhe

a purse_siring
right atrialappendageusing3:O poLypropylene and a Rummel tournlquet'
and encirclingthe supradiaphragmaiic IVC insidethe pericafdiumwiih an
g
umbilcal iape on anoiher Rummeliournlquel We use a size
endotracheal iube, clampedproximally, with a side_hoe cui 17cmJromthe
tio. We insertthe shuntwiih the curue the lube facinganterlorlyso that
of
the lip does not end up in lhe hepaiicveins The surgeonoperatingin the
abdomendirectsplacemenito preventshuntefrusion throughthe injury
The baloonor lhe IuoPoovia-es lhe needror encrc ng t1e s'lora-erel
IVC in the abdomen.The shuntdoes not providea completelydry field bui
ooes arlowyoJ to see .he inlLryand gel Io t

- don't be a hero
venousiniury,restorecontainment
ln retrohepatic
 IOP KNIFE
TheArt & Croft of lroumo Surgery

The "evil green eye"

For obvjousreasons,injuriesto the bjliarytraci are often assocjaled

with hepatictrauma,and leakingbileis a jowerpriorityihanspurtingblood.
What are your damagecontroland definitiverepairoptionsfor the injured
biliarytract?

A perforatedgallbladdercan be repared, drained,or femoved.The

definitivesolution is that rare, almost extinct operation, open
cholecystectomy.ln a crashing coagulopaihjc patient, taking the
gallbladderoff the liver is not the smartesimove in the book. tnstead,
eitherrepairthelacerationwjth a singlelayerofabsorbablesutureor drain
the gallbladderwith a cholecystostomy tube insededthroughthe injured
fundusand securedwith a purse-stringsuture.

The damagecontrolsoluiionfor cor.mon bile duci injuriesis exiernal

drainage.lfyou needto bailout in a hurry,cannulateihe proximalduct and
bring the drain out throughthe abdominalwall. Ligaiingor clippingthe
commonduct ofa patientin dire siraighisis an acceptabledarnagecontrol
opiion,but will requirea complexreconstrucilve solutionat reoperation,lf
you can'l see ihe leakinghole,a drain in Morrison'spouch is good
enough. The leak can be managed later by ERCP and endoscopic
stenling.

lf you can clearlysee ihe injury and the com.non bile duct is wide
enoughto accommodatea T-tube,this is a good bailout option.However,
the common bile duci of most young irauma patients is narrow and
delicate, and insertinga T.tlbe into it may well buy youf patieni a
posloperatvestncture,

The definitiverepair of extrahepaiicbiliary injuries depends on the

magnitudeof damage.Repaira simplelaceration(partialiransection)with
an absorbablesut!re and an externaldrain.Allhoughit is not mandatory
we lnserta T-tubein the commonbile duct if it is of sufficientcaliberto
accommodaieat /eastan I Frenchtube. If you decide io use a Ttube,
alwaysinsed it ihrough a separaiecholedochotomyratherthan ihrough
the Inlurysile to prevenia stricture.
 6 The Iniured LlvenNinio Moner

Deflnive repar of completeor near_compleie transeciionof the bie

duct is with a Roux_en Y hepaiicojeiunoslomyBefore you begrn' a
cholecysieciomywillfaciliiateaccessand exposureof the injuredduct

Drainageis the bail out solutionfor biliarytrauma

THE KEY POINTS

) usinghand,pack,or clamp
Controltheliveftempofarily

) ihe iniuredlobe to deal with it face{ojace

lvlobilize

> Decideif you are dealingwith a smallproblemor BIG TROUBLE'

) as an adjunciio packrng
Considerangiographicembolizaiion

) are noi a crime

Deep liversutLrres

) Hepatotomywiih selectivellgationis easiersaid than done

) FiLllargeparenchymaldefectswith omentum

) Balloontamponadeis a cool soluiionfor a bad problem'

) Perfom reseciionaldebridementin healthyliveriissue

> venouslniury'festorecontainment'don'tbe a hero

In fetrohePatic

) Drainageis ihe bail out solutionfor blliaryirauma

TOPKNIfETheAri & Croft of TrqumoSLJrgery
 Chapter 7
'Take-outable"
SolidOrgans
The

Fot eztery complex ptoblem, thete is a

solution that is simple, neat, dnil Tototrg'

- H.L. Mencken

Althoughthey belongto differentorgan systems,the spleen, kidney,

trauma surgeon's
and dlstal pancfeashave a lot in common From the'iake_outable '
perspective,they af€ close relativesbecausethey are

Considerthe fundameniadlffetencebetweenan injuredspleenand a

bleedingliver.The spleenhasa singleaccessiblevascularpediclethatyou
can rapidlygel io and control The liver hastwo vascularpedicles(onein
lhe hepatoduodenalligamentand ihe othor behind the liver where the
hepaticveinsdrain into the IVC), only one of which ls easllyaccessible'
Toialvascularcontrolof lhe liver is, therefore,iricky businsss lt is noi a
take-outableorgan in the bleedingiraumapatient.

It n6vermad€ senseio us to considerboth head and disial pancreas

(body and tail) in ihe same chapter'From lhe iraumasurgeons poLntol
view theyare differenlorgans The distalpancteascan be easilyresected'
whilethe panctealicheadrequLfes a verybrgwhacK

The spleen,kidney,and distaLpancreasare take_oulable abdomlnalsolid

organs.They can bleed a lot b€fore you get to them, bui once you have
gainedcontrolof the vascularpedicle,bleedingstopsimmediately The key
to vascularcontrolis mobilizingeach organand fting it towardthe midline
In starkcontrast,resectionof a
'non'take_outabe ' so d ofgan such as lhe
technicalundertaklng
liveror ihe headof the pancreasis a prohibiiive in the
lraumapatientunlessthe injuryhas done mostof the resection tor you'

At firct glance,bringingtogetherthreesolidorgansfrom threedifferent

organ systemsunderthe same foof may seem strangeto you Bear with
 IOP KNIfETheAri & Croft oJTroumoSurgery

and comfortjevelindealingwith theseinjuries

Lis,and your undersianding
will grow

Thespleen,kidney,andtailof the pancreasaretake-outable

The spleen

Mobilization

If you see or suspecta spienicinjuryyourfirst movemust be mobilizing

.
the spleento ihe midline.Youcan nejiheradequatety assessnof repairthe
spleenwiihout havingii tn your hand. Mobilizingthe spleen is the key
maneuverthat unlocksthe left upper quadrani.lt bringsthe sp/eenand
drstalpancfeasoui of the dark recessesof the abdomenjntoyour incision
and exposes the left kidney.White mobitizingthe spteen is a basic
maneuverrn surg€ry,pedormjngit quickty,btindty,and tn a poot of blood
is not as it appearsin the illushaiions.

Mobilizethe epleento unlockthe left upperquadrant

Youmay not haveheard this before,

but in reality(as opposedto the virtual
world of the surgicalatlas),ihere are
two kindsofspleens:mobileandsiuck.

The mobilespleenhas lax spleno,

renal and splenophrenicligaments
and no adhesionsto the abdominal
wall. By putting your non-dominant
hand over the splenic convexityand
pullingmedially, you can brng the
rnobilespleentoward you, almostio
the rnidline.You still have 10 cut the
splenorenalligament behind ihe
spleen,but this is easy becauseyou
do it a/mosiin the midlineraiherthan
high up in the left upperabdornen.
 7 The Toke-oLrtobleSoicl Orgons

midline'you
The siuck spleenis, you guessedii' siuck To gel it to the
the
have to deal with two obstacles.The firct are adhesionsbeiween
wall ihat will not let you pass your nano
spleniccapsuleand lhe abdominal
lfihere is littleor no bLeeding, youcan takeyour
overthe splenicconvexity-
But if you
iime and ;harplydivideihe adhesionswith scissorsor cautery
quicklygel them
are workingin a poolof blood,just do whaleverittakesto
oui of ihe way with yourfingers,scissors,or boih Damage to ihe splenlc
capsuledoesnt matiersinceihe sPleenis comingout anyway

The secondobsiaclewiih ihe stuck

spleen ls a short and unyielding
splenorenalligament.Put your non-
dominanlhandover the spleenso the
tips of your fingers resi on the
menrbrane behlndand lateraltoit This
is the splenotenalligamenlGentlypull
the spleentoward you io stretchihe
ligament.Workingin a pool of blood,
you often cannotsee [, bul you can
easilyleel it. lmmediatelybeyondthe
tips o{ yourfingers,makea nick in lhe
wiihyourscissors
streichedligament
Enlarge sharply
the-nick (withscissors)or bluntly(withyour{ingers)up
anda;oundihespleenBoththesplenorenaland splenophrenic Ligaments
are avascular'and dividingihem
allowsyou to bring ihe spleento ihe
midline.

Palpatethe left kidneyand bluntly

developthe planebehindlhe spleen
and in iront oi the kidney,bringingthe
spleenandtailof the pancreasup into
the wound.The piifalLhere,especLally
in the prcsenceof masslvebleeding'
is going behindthe left kidney and
discovering thatyo! havebroughtlt t0
the midline wiih You.
 TOPl(NtFEThe art & Crofl of TroumoSurgery

Once the spleenis mobilizedand

in yourhand,bleedingcontrolis not
a problem. Pinch the splenic
vascular pedicle, which includes
boih the gastrosplenicligament
(carrylngthe shod gasiric vessels)
in front and the splentc hitum
behind. Alternatjvely,place a soft
bowel clamp or a large vascular
ciamp globally across the entire
pedicle if you have other urgeni
businessto aitendio first. Think of
t as the "Pringlemaneuvefof ihe
spleen."

Rarely,on a particutartybad night, you may find yoursetfgazing in

disbeliefai the rupturedspleenfrom hell, a diseasedorgan so enlarged
and stuck to the abdominalwal/ and diaphragmihai rapidlydevelopinga
planebehindii is slmpy oul of the question.ln this case,your only option
rs 10altackthe spleenfrom the front.One qulckway to conirolthe splenrc
arleryis to enre.rhe lessersac lhrougnthe gastroco ic omentuma,to
isolateihe arteryalongthe upper border of ihe pancreas.AnotheroDtron
is io go srrarghtal lhe hilLm.Gentrypulltne stomachtowaroyou Loput tlF
gastrosplenic ligament on tension and divide it between clarnps.
lmmedialelybehindrt you will find the splenichilar vesses. Clamp them
and onlythen startyo!r dissectionio fiee and mobllizethe devasculafized

Do whatit takesto bringthe spleento the midline

Remooeot rcpab?

Youarenowfacingthekeyslrategicdecision
ln sp/enictrauma:
romove
of repair?Splenectonry
or splenorrhaphy?
 7 The Tokeouiobe solldorgons

Youranswers10the iollowingfout quesiionsguideyour decLsron

1. What is the patienls traun''a burden? Ongoing sl^ock s"vere

_
associatediniuriesin or outsldethe abdomen all are indicationsto
rapidlyPut th€ soleenIn a bJclet.
2. Whai is the patieni's age? Spenjc pr€seruaiionis much more
importantin kids. Splenonhaphyalso works betier ln the pediatrlc
spleenbecauseit has a lhick capsuleihai holdssuiuteswelL'
3. iow bad is the iniury?ls a repairllkelyto work? ls therea hilariniury
that makesrepairmuch more dif{icuh?Will a r€pairentailadditional
bLoodloss? Nevermakethis decisionwilh ihe spLeenin siiu Always
bringitto ihe midlineandassessthe lnjurywrththe spleenin yourhand'
4. Wh;t is yourexperiencewilh splenictepalr?Haveyou done it before
'readons, do one'siluation?ls the injuryamenabLe to a
or is it a
reparriechniqueihat you are comfortablewiih?

Forsplenicrepair,considertEumaburden,age,injury,andexperience

t compteungthe s1lenecto,nq
,l

."tt /' CJi""'y Lo the imor€sson you may havo fro.r readingthe rauma
7 literalureol the pasl decade,splenectomyis not a crime lt is otten ihe
I
safest and mosi expedientsolution One very effectlvetechnique of
splenicpreseruation is the {omalin jar

Once you have the mobilized

spleenin your hand,comPleling
the splenectomyis easy Clamp
and divide the vessels of the
splenic hilum from the back or
side, whichever Ls mosl
convenieni.The key technical
prlnciplehereLsto stayverycbse
to thespleenso youwillnoiinjure
the tail of the pancreas or lhe
siomach.Fot the sake of sPeed,
 TOPKNIfETheArt & Croft of TroumaSurgery

camp oniyihe proximalside of the lineof resection.Clarnping

the spleen
srdewastestime since it comes out in a momentanyway,Seriallyclamp
and dividethe gasirospJenic
ligament,takingcare to stay away frornthe
gfeater curve of the siomach. The splenocolic ligament is ihe only
remarningattachment.Clamp and divideii, and the spleenis out.

Now pick up the ciamps one-by-one,and ligatethe vesselsihey are

controlling.You may declde to doubly ligate or sutureligatethe hilar
vessels.Re-examine the greatercurue of the stomachto ensureyou did
not accidentallypinch the gastric wall. Much has been written about
ratrogenicjnjury to the tail of the pancreasduring sptenectomy.Thjs
concern rs much overraied.lf you think that you may have iniuredthe
pancreaswhie removingthe spleen,leavea closed suctiondrain in
the
splenicbed.

Lasty, check for hemostasis_

Suckoui alltheb oodandclotsin
,..\ the splenic fossa. Take a tighty
rolled laparotomypad, go io the
ij
deepestpart of the splenicfossa,
and slowly ro/l the pack ioward
you medially,overthe area of ihe
pancreatic tail and the greater
curve. ll you identifya bleeder,
stop rollingand dealwith it.

Staycloseto the spleen

\ ^ Yr{
Fixing the injurcd spleen

lf you decidedto repairihe spleen,use ihe simplesttechnicalsolutron

thai will work. Choosefronra limiiedmenuof repairrechniquesthat have
worked fof you in ihe past. Few surgeonshave experie|cewjth a vasi
arrayof spjenjcrepairmethods.What are your realisticopiions?
 O'ncl"t E
7 TheTokeoulobe SoLid

pachl wor\s in super{'cia

Local pressJ'e lwrlh yor- hand-or a rocdl hemostaircagert
laceratro']sand capsLlaravu's;or- Your lavorfte
if availab/e'does wondersfor
.f". n"fp fn" ,q,g"n beamcoaguiator'
""" rawsurfaceor a deeperlaceration-
a larger

Because the caPsule of lhe

ad!lt spleendoesnot holdsunrres
w€ll, use a rnonofilarnentsuiure
ihat slides through the tBsue,
alongwith someklndof bolsteror
support.Our PreJerfed technque
is runninga mono{ilament suture
needle
on a straight between two
stdps of Teflonon both sides ol
ihe laceration Sorne surgeons
useomentumas a boLsler.

pole ray r"qu're a "mired

A severeryrlu'ed or o^vitalireosoleniu
;;;". #"" ;"", manuallvcompressthe spleenlusi bevond
"""istant reeasi'gihe
;;,;;""" li." ;' '""""Ion .o conrolb'eedirglntermit.ntlv
are-ovo"r:::':lH
0."J",'".**. t", **'e theolPeders T,i.il
Argonbeam Youcanthen
oversewthe op6n splen|c
'siump' with mattfess
suturesbetweentwo sirips
of Teflon.lf the sPleenLs
flai rather than bu kY,
anotheroPtion is using a
linear staplef wiih 4 8mm
staples.Bring the stapLer
io the line o{ transection
and slowlyclose I so as
noi to break the caPsule.
Fire ihe staPler and
amputaiethe sPlenictissue
disialto the staPledline.
E ,o, ^",r, rn" o,, & cfofl of Tfoumo
sureery

Don'tpersistifyourrepairdoesn,twork,and
-, don.ireiyon thepatient,s
Cott'ngmechanism to siooorgoingoozirg.,lf i air,,ary.,t s noi
In ar adL[ patient.we proceedwttn splenectomy wor"r,.g."
i, rhefts, aftemp;d
repairJaits.
tf yousirongtybetieve
thairepairis stifitf.,"Uu.toptiontofifrJ
palient,youmaytry a second
time_A tniraatremptrsptaying wirhfjre.
Wehave.g:ven youihFhmied.ienu of sptenrc ,echniquFswe
rsoair
_ Lse
sorryif you are disapporn,ed.We have,itr,eexperielce
:,:1:li::i"",
wllr Tormat tem,splenectomyor tre absorbabtemeshwrap.We consioe.
rnemunlecessaflly riskyacrobaics.lr siuatonswherethesetech'rrques
wouldbe requhed,we preferio en on the
srdeot cautionand do a
sprenectomy.

Don'tpersistif splenorrhaphy
doesn,twork

The distal pancreas

ENplolation

Youcanhavea quick'rule
oui' look at the body and tail
of the pancreasthfoughthe
lessersac by poking a hole
In the gastrocoiicomentum
on the teft (Chapier 4).
However, if you see or
suspectan injury,you needa
wrde exposure. Have your
asststani pull ihe stomach
upward and ihe transverse
corondownwardrand detach
the greater omgnium from
the transversecoJon a/ong
the bloodless line io open
the ful/ width of the tesser
sac. Wjih any sign of Injury,
 7 Therake-oirioblesoioorgonsI

the injured area What.you

open the posterior peritoneumoverlying
or superrical
;;"";; i" be an innoLenr-lookingminor hernatoma
*,, .f,"^ oro"e a s€t;ousInjurywh"n you un'oo{ and look il in
it
i"""*."
fie lace.

For signi{icanlinjury, and

especiallyif You are going lo
resectthe dislalPancreas,the
quickestway io bringihe body
and tail into{ullview (including
the posterior asPeci of the
gland)is to mobilizeit out of ils
bod. Mobilizeihe sPleenand
continueto develoPihe Plane
behindthe Pancreaticiail and
body until it can be lifted
medialLylnto the operative
incision.DistalPancreateclomy
without splenectomy rs an
€laborate exercise suitable
mosilyto an electivesituatron.
We do not recommendnor use
it in traumapanents.

left
Iook the pan"reatfrom the front - but mobilizeit from the
"t

Decision
assessrngIne
ls thete a ductal injury?This is the key quesuonwhan
see that ihe pancreasls
iniuredpancreas someiimesyou immediately
in a deep wound ['4ore
;;;;iJ vou can rdenlilylheinruted duct
'niury and palpanon
ot you ", tu," out a duclal basedon Inspeclioi
"n, ""n;ot
alone.What then?
E ,o, *",rr rn" orr& cfqfj of Troumo
surgery

ln a stablepatrentwiih no othef
maiof
inir
e,ercise cared,nraopar,, r";;.;;;:;#;:;jJ:i;T,:lj"'j;::ilI:
-catn.rer
II.e ga,'bladderrrrough a ";
reedle and aro pray rhar rt n,ts tre
pancreaticduct in a retfogradefashron
ihrougt th" urputu. eropon";ii
of this technrquecJaimji works about
half the time. In
ra,'elydoes. B.euaLsplhey a,e torattyLnnece,sary, "rl. ",,p";i;n";;;
we don | -euommero
olTeropfonsI ke ampurat ng tneta,ror tre panc.ea5lo n^othedJc-or Ine
absurdnotionof makinga duodenotomyio
cannuJate the papilla.
r:: c:Tmon sense..\pedien-aop,oacr.f Fypto.aion
-^Y" !':*
revears a oeepInJUry liJ<ely
to..vorus,1.,"
6u"', Oo 1ol hesitatero pertor_
a orslatpafcreaiectomy,evenwiihoutdefinitiveproof
of ductatinjury.lf we
*':""1 w" ,,""" o.",n
baitoL,oLiLkty.
P:^r,]:l
'o lhe InJLry "."eed-o
dnd perform ";;;;;;,
" ihe operairor,
ar ERCp as \oor as oossib,eafte.
fealizrngthai we may occasionally have
ro go tJack for a disial

You don't need photographsto deal with a pancreatic

injury

Hemostasis alriL ahg Mge

The damagecontrolsoluiionfor injuriesto the pancreailc

body and tail
rs hemostasisand drainage.pack *e lessersac
for hemosiasis.A drain
converlsihe injuryfrom a potentialuncontroliedpancreatic
leak into a
controlledfisiulaihat has a befign courseafd can be
addressedlaier

mdnagFmenr oi mosrdrslarpanc-eaicinjLriesis no_-uch

,.Def.ni:vF
1l^edamageco'lnotooiro'l.Slop b,eFdrrgfrom supFtiL
iil'":' "* andconlusions a,
raceratons usinglocalhemostatic means.Don,tsulureihe
capsuleof ihe pancreasbecausethis js askingfor
trouble.Leavea Jarge
suctrojldrain,(ortwo) adjacentlo the injury,feed the patient
as early;s
possrbre,and renrovethe drain when it stops
working. For pancreatic
injuriesthat do/r't involvethe duci, ihis is a yo! need
to do.

*",s ooviousouda :njuryor when you have d srrong

^suspruror
^ryTl aboutthe
d rct bur ua-no-proveil. do a drsta,panc.eatecromyi
 7 The Toke-ouiobleSolidOrgons

lf you happento come across the

pancreata duci, ligate it Otherwise,
don'i spend time looking{or it. Liit
the spleenand the Pancreasto the
midline,lake a linearstapler,placeit
across ihe body ol the Pancreas
includingihe splenic vessels,and
shoot.Amputaiethe disialpancreas
and spleenand give the Pancrcatic
stump a close look Control any
bleedingfrom the splenic vessels
with a hemosiaticatiich.One ol us
usuallyundeffunsthe siapled line
with a 3:O monofilament non-
absorbablesuture;the other nevet
does. Don'tforgetto leavea closed
suctiondrainin ihe pancreaticbed

Damagecontrollor the distalpancreasis hemostasisand drainage

'+ @ *"*tH
-''N5t(^\D\--
Thekidneys a s!,rl,r" + c.^l,alt r'.-{,&}.-&

Access&ndotlscttltu contxol

At laparotomy,the iniufed
kidneyiypicallypresents as
a lateral feiroPentoneal
(perinephric) hematoma
(Chapier 9). Deal wth a
massivelybleeding kidneY
in an unstable Patient b),
rapid mobilizaiion and
contfol of the vasc!lar
pedicle,just like You deal
with the iniured spleen A
E ,o, *"'rr rn. o,r & crofiorTroLJrno
sursery

mediaivisceralrolation(Chapter 4) on the leftor on the rightgivesyou

ftpld accessto the injuredkidney.InciseGerota'sfasctataieratty anj iift
the kidneyout of its bed.Nowyoucan pinchthe hitumwithyourfingers
andcarefully
placea vascular clampacrosstt to controlthebleodino. The
obvioussjmilariiy
to th6spleenis stfrking.

Bring a massivelybleeding kidney to the midtjne

lf you must explore a

pennephflc hematomaIn a
Egllq) patjent,you can gain
vascularconirol of the renal
vesseJs at their origin by
using a maneuvercalled
nidline looping. Wilh this
maneuver, youobtainproximal
control prior to entering the
hematoma,but ai the price
of tedious dlssection. The
lrrst moves are essentially
those of infrarenalaodic
erposure, Evisceratethe
small bowel and pull it up
and to the right. Takedown
the ligamont of Treitz and
openthe poateriorperiioneum
overlyinglhe aorta.First, identifythe LRV crossing in front of ihe ao a
beneaththe infefiorborder of ihe pancreasand encirce t with a vessel
loop. This is the first of four toopings.Very gently reiraci the LRV
downward (withoui avulsingthe adfenal, left gonadal or lumbar veins
that branchof{ jt), and you will gain accessto the left renalarterytaking
off irom ihe ao a behindand abovethe LRV pass vour second vessel
looparoundit.

Midlineloopingis trickieron the right_you must first identifyand looD

ihe srorl right'enal ve:n:then. dissect n tne wrndowbetwee; t and tne
IVC to oop the right renalarieryas it emergesfrom behindthe IVC. AJI
 7 The Tokeouloble Solidorgons

this is iime_consuming and opensthe door io potentialpitfalls We

get
considerit a longrun{or a shortslideandrarelyuseit Youcaneaslly
rapidlylifttheinjuredkidneyio themidline'
tv withoutit if vo-urememberto
iusias youdo wiihthe sPleen

What af€ the damage

control opiions for renal
trauma? One obvious
option ls nol to explorethe
kldney. lf the PennePhnc
hematomais slabl6 and
non-expanding,leavo it
alone.lf you see oozingbut
no massive hemorfhage
through a hol6 ln Gerota's
{ascia, pack the krdney
Remember thai urine
exiravasalion|s much less
ominous than leaking
intestinalconteni (Chaptet
4).

lo
lf the kidney is bleedingmassivelyand is obviouslynot amenable
ot has a hilarvascularlnjuryin with
conjuncrion oiher life_
reconslruction;
lhreatening iniuries,a rapid nephrectomyis lifesavingLift lhe mobilized
tie off
kidneyup, id;ntify the arteryand vein, sutureligatethe arteryand
ligaturesand pui the kidney in
ihe v;in. Then, divideth€ ureterbetween

When consideringyour oPtions,alwaysthink about the contralateral

in renal
kidney.You will go the extfa mile and invest addltlonaleffod
preservation ifyou knowthatthe paiientdoes not haveanotherfunctioning
iidnev. lf voudo not havepreoperative imagingto proveafunctloningrenal
intravenous
mass on the other side, what should you do? An on_table
renalmass
oveloo.ar to proveihe presenceol a lLnciionng confalatera
-e and otler yieldsan rrialing lLzzogramralher
is ore'option.Tl^istakest
kidney lf
than a satisfactoryimage A betteroptionis to palpatelhe othet
urine
it feels normalin size and consistencyand the patientis making
 TOPKNIFEThe
A.t & Croflof]rounroSurgery

despiiea.hilarclampacrossthe injuredkidney,the riskof postoperative

renaldysfunctionis verysmall.

Palpatethe contralateral
kidney

Repaif.oplionsJor the injuredkidneycover a wroe epectrumjranging

.
lrom applicationof topicalhemostaticagenlto extracorporeal benchrepair
wrth auiotransplantation.The best advicewe can give you is don,t use
them. CaJla urologistin to repairthe kidney.An experiencedurologist
is
more likelyio achievea good result,will foliow the patieni,and m;nage
any cornpllcanons.
V,r ^ 1
/.1-J
Repairof renalvascularinjuries(bothbluntor peneirating)is muchiess
coramonand rnore challengingthan the trauma iteratureleads you to
believe.On the right srde, penetfaiinghilar injuriesare iypicallypart
of
woundsto ihe surglcalsoul one of the most devastatingcombinaiionsof
injuriesin tfaumasurgery(ChapterO).The proximityof the renalhjtumto
ihe IVC meansthat a penetratinginjurywill involveboih ihe renal artery
and lhe IVC or other adtacentsiructlres like the pancreaticoduodena
complex.Inj!ry to the short fight renalvein is essentiallya side-holein ihe
IVC,for whlchthe pime concernis controlof liJe-threaiening hemorrhage,
not renalsalvage.On the left, don'i hesitateto ligatethe renalveinif it ts
Inured proximal to its gonadal and adrenal branches. The N4attox
rianeuver(Chapter4) givesyou excellentaccessto ihe left renalartery.

When dealingwrth an ischemickidneyafter bJuntiralma in a stable

patieft, your decision to revascularizeihe kidney hinges on ihe Ume
elapsed since injury,presenceo{ functionjngcontralateralkidfey, the
patienis overalltraumaburden,and availabieexpertise.l\,,lanyof these
Inlunes are amenableto endovascularstenting, Never jeopardizethe
patient'slile to savea kidney.

ll you are fixingan inj!red renatariery,perfuseihe kidneyintermlttently

with iced heparinizedsatineand choosethe sjmplestrepairoptiof. Jfthe
artery can be repairedend-to-efd,go for it. More often, you have io
interposea graft. The graft of choice is probablya reversedsaphenous
vein,bul ihe most expeditiousoptionjs a 6mm epTFEcondujt.Hook it up
 g
7 TheTake-outobleSolidO,S.",

io ihe renaladery (distalanastomosis) firstbecausethisallowsyoubetter

," tr't" posterlor*atl of the anastomosis Choosea convenient
".|e""
L"ationontnelat"ratu"pectof theinftarenal aoria'convolii wiih a side-
graftand comPlete the
Uiti"gautp, anddo a smallaoriolomyTrimthe
pror-malanastomosis lo the aortotomy in anendio sideconfiquration

Don't killthe patientwhile kying to save a kidney

THE KEY POINTS

) The spleen,kidney,and tail of the pancreasare take_ouiable

) Mobilizethe spleenio unlockthe left upperquadrant'

) Do what il lakesto bringthe spleenio ihe midline

) For splenicrepair,considertraumaburden' age' injury'andexperience

) Staycloseto ihe spleen

) doesnt work
Don t persistif splenorrhaphy

leJi
) Look at ihe pancreasfrornihe tront-but mobilizeit fior' the

' You don't need photographsto dealwith a pancreatlcrnlury'

and dfaLnage
Damagecontrolfor the distalpancreasis hemostasis
)

) Bring a massivelybleedingkidneyto the midline

> kidney
Palpaiethe contralateral

) Don t killthe patieniwhileiryingio savea kidney

E ,o. *",rr rn" o,r & crofiof Troumo
su,sery
 ChaPter8
The Wounded Surgical Soul
(vQ i^ "/''r+vu'!
e t ')u7
t!a-,.'a^*

Medicalill stratorsarc optifiists.

- Matthew J. Wall, Jr.,MD

It's dilficultio imagne

a more unwelcomesight
during laparoiomyror
penelraiingtrauma ihan
a arge hematomaor
vigorous bleeding kom
the dght upper quadrant
beneaththe Liver. l{ ihis is
what you see, you have
just beendealtone oi ihe
worst possiblehands in
the lrauma game. We
l.
call ihese injuriesthe
wounded surgical saul
Accordingto iraditior in
area'
our hospital,ihe seat of the soul of lhe injuredpatientis a sphencal
pancreas
not muchlargerthana silverdollar,centeredon the headol the
They afe calledsoul woundsbecause they are mofe lethalthanany other
type of abdominaltrauma

A glnshot to ihe surgicalsoul commandsihe greatestrespectfrom

trarmi surgeons because it frequently eads to intraoperativ€
exsanguination. You may initlallyencountera containedor slowly
ominous But once you
expan;inghemalomalhat doesn'i look particularly
are
open it and unroo{the underlyingmajorvascularinjuries,the demons
in your hands Another
unleashedand the patient exsanguinates
a soul
unwelcomes!rpdse is whena novicepokesan exploringIingerinto
is
wound, onLyio face torreniia hemofrhagewhen the ptobing finger
withdrawn.Why are these nluriesso Problemaiic?
E ro, *"'rrTn. o,r & CroJioJTfoumo
su,oerv

First, considerthe vascuJaranatomyof the area.The portal

vein, the
s!penor mesenteficvessels,the pancreaticoduodenal arcade,the IVC
and the righi renalpedicleall convergeai the surgicalsoul.
Sincesomeof
ihese vesselsdirectly oveflayeach other, a penetratinginjury
iypically
in/olvesmorethanone majorvessel.Now consrderaccesstbtlty,
The neck
or tlre pancreasoveries the podal vein conJluenceand the proximal
superior.meseniericvessels.The pancreatichead and duodenal
loop
(reJerred to in ihis chapteras the pancreaticod!odenal
complex)coverihe
IVC and right renalpedic/e.So, none of ihe vesselsis easilyaccessible.
The situatronhas worst-casescenaio wrjnenal/ over it. A discipllned
and
priorrty,oriented approachis your only hope.

Immediate concetns

Yolr first priorty wlih soul wounds is to contro her.orrhage.Always

assr.rmelhal bleedingis from more than one major vascularinjury unti
provenotherwise.The major bleedlngsourcesafoundthe surgical
soul
are arrangedin ihree layers:deep, middle,and superfrciai.

L fhe deep layer includes

ihe IVC and the righi renal
pedicle. You will see a
raprdly expandingrighr-
srded retroperrioneal hem-
atoma or active bleeding -\ji.'.------'-'-.

\:1,--:1.)
from the area of the righr
renal h Ium- Pack or
manuarry compress it.
Don't unroofit.
2. fhe niddle layer irc)udes
tfie retropancreatic
vessels:
the superior mesenteric
artery (SIMA) and vein
(SMV),and the portalvein.
The secret of tempofary
b eeding control ts rapid
mobilizationwith a Kocher
 g
sThewoundedsursrcosou

the rool ot lhe mesentery

maneuver(Cl'dple'4). lf bleedingis {ron
yourlelthand
it byinsinuating
control
iJ"t i."rJ., ,"f *" o"ncreas'
andpinching
s.i-i"a'iil ."t ortr',..eseniery ihumband
it beiween
mdnJally
{oref,noer.l{ the sourceo{ bleedrngis beh no the oarcreas
t're ent're pancreat;coduodenal complex Temoo'anLy
"ompr'"ss
control bleeding fiom the hepaioduodenalligamentby pinchingthe
portaltriad (Chapter6)
3. fhe su?erticial laYer
consistsof ihe iniured
pancreaticoduodenal
complexrtself.Injuryio
the head of the
pancreas can be lhe
sourceof brisk bright_
red bleedingfrom the
pancreaticoduodenal
vessels, Here again,
ihe quickest way to
gam temPoraryconrrcl
is a Kochermaneuver'
which enablesYou to
comPress the entire
pancreaiicoduodenal
complexin Yourhands
of encircle il with a
Penrosedrain lo gei
temporaryhemostasis

while others
Some soul woundsbLeed{reelyinto the peritonealcavity'
DTesentas a conlarneohe_laromaCo'Irol o'i'ee bleedingcomestlrsl
'pote skunk'by enrenrga coniained hemaLomd unli all1€e
Neverever a
your attack'
bleedinghas been controlledand you haveorganized
patient
Supraceliacaortic clampingis a usefuladjunctin a cfashing
aorta
infrarenal (to control
Doubleclampingof bolh the supraceliacand
mesenlenc
backflow)helPsreducebleedingJrominiuriesto the superlof
field'
vesselsand the portalveinbui will nol dry up lhe operative
E ro, **,rr rn" o,i & croit of Tfoumo
sursery

All this seems nice and neat when siiijng at home

, readjng(of writing)
about ii. But the professionalterm for what you meet
in real life is mulr.,
tocal exsanguination, rapid bleedingfrom muhiptesources,none of them
easyto control.A less professionaltermis bloodymess,
and you haveno
r/meto consuttwww'broooymesc.org fo. aov.,e,roJ must starncnrhe
b/eedingNOW usrnga coF,binatio'r of odckng, the Kocrer mareuvel
manuatpressure,and carefulclamDino

once you. have gain.a t"mpo*r; c*trot oi hemorrhage,

stop ihe
operationand organizeyour attackon the injury.Don,tjusi
dive tn wlihoul
appropflate Instruments,plenty of blood units if ihe
OR, an auto-
t'ansfus:ondFvtcp.a rapid,nfLser
oolimdlexposu.e. anocomoetenr help.
rl'eeorrgrro- d soulwoJrd rdkesBtG IROUBLE{Chaptpr
2) to a rew
level- TREN4ENDOUS TROUBLE.

Soulwoundsbleedfrom morethanone vasculariniuru

Imptoving exposure

The keyto anfhing you

may need to do around
ihe surgtcal soul is ihe
wrdesi possjbie Kocher
maneuver(Chapter 4).
For bleeding from the
deeplayer(lVCafd right
kidney), extend the
Kochermaneuverinto a
full right-sided medial
vrsceralroiatronby mob-
iJizingthe right colon and
retractthe liver cephaladto create a wofk space around
the pararefal
lVC. lf the rightfenathitumis involved,
mobilizingthe rightkidneyout of
Gerota's fascia afd rotating it mediallyhelps you gain control
of ihe
hilum.
 I T h ew o L r n d e dS u r g i c o l S o u !

Use the Cattell_Braasch

maneuver(chapier4) io obiain
lhe widestpossibleexposureoi
the sufgical soul This
maneuveruncoversthe third
and fourth Parts ot the
duodenum,allowsYouto reach
ihe pfoximalSMA and SMV as
they emergebeneathihe neck
of the pancreas,andevengives
you some access to ihe
c ponalveLn
relropancreat

maneuverto exposethe surgicalsoul

lJsethe Cattell-Braasch

The supraduodenalPortal vein

with a high_
InjLiryto the supraduodenalPorialveinis usuallyassociaied
'rju-y ano p'esFnls as a hematomaIn the hepalodJodFnaL
orade iiver
ioament.
- The Do,JblePingte -aneuver rs the texlbook_recornmendpd
techniquefor de{iniliveconlrolol
injuryto the portaltriad,including
the suptaduodenal Portionof the
ponalvein. Beginwith a Kocher
maneuver;then, comingfromthe
right hand side, Place one
vascular clamp irnmediatelY
above the upper border ot the
duodenum. Place a second
vascularclampacrossthe portal
iiad, as highas Possibleioward
the liverhilum.This allowsYouto
open ihe serosaof the hepato_
duodenalligamentand carefully
E ,o, *",rr rnuon & crofrofTroumo
surgery

o.ssecllo derile the iltury. UnfoaunarFty,

lhe hFpatoduooenalligamentis
oner too shorito acuommoda,e two clamps.A good ahe.native
is pinching
Ine InlL'edar€a wth yoJr,eJlha'ld whiledissecting
dboveand betowihe
injurywith yourright.

A/waysassessall threeelemeftsof the portaltflad

becausetheirclose
prox/mfiymakesii very likelyihat moreihan
ore siructurehas been hit.A
siab iypicallycausesa cleanlacerationof the portal
veinand js amenable
to a e'al repai l- contrast.gLnsho,.n,uiesLaJSF
Tasstvedesiuciron
tusuartyrr coryunctior
wrtha.irer ir'ury1.reoLinlga complFx repairs,ch
as a patchor rnterposjtion
graft,which is rarelyfeasiblein the harshrealiiy
ol multifocalexsanguinatron.

The oamageLonro' soturonlof a como,ersupraduodera,

porat var'1
rrlJry.r lgar'on.lt rs a realistic
optiol and co-pa.ibtew tr sJrv.va.
ir the
repalrc arteJ ts intacr.Wher bo.h porta, veir
and hepatic anery a-e
rrlured,you haveto reconstructone of them

Ligationis the bailout solutionfor portslveininiurv

The retropancteaticvessels

InJunesto the retropancreatic

vessels(the confluenceof the superior
mesentencand splenicvetns,as well as the reiropancrealicpart
of the
SMA) are particularlyjethaj becauseyou can,i get to them. pancreaijc
rfans-Aclonacrossthe neck exposesthese injuries.One
of us finds this
techniqueusefuland lifesaving,whilethe otheravoidsdividingthe neck of
the pancreasunlessthe jnjuryhas done it for rrm.

To transectthe pancreas,compressihe breeorngpancreatrcoduodenal

complexwith your left hand to temporarilycontrol the
bleedifg. Do a
co-.]pele Cafel-Braasuh maneLverro oplimtzFacLess io
'rom all s.des. the complex
Rapiorycreatea relropancrea,ictun,reloy openingtre
hepatodlodenailigamentand blunflydissectingimmediatety
to rh; teft,
anterior to the common bile duct, and behind the pancreatic
neck.
Transectthe neck of the pancreasusingihe cauteryoveryour
finger,but
 surqicolsoul
8 rhewounded A

inlo lhe lunnelbecause

avordot-shingInsfumentslc'amps or slaolPrs)
'njJ'y Cudng rhe
t"." ,l^" a retopancleai'c porta' vei'r
""',rt"""," tace-loJacewith rhe iniu'ed ra'ge vein Lnde'nearl^'
u.i"n" v.,
""ri".""i
Ii"^-t", ," to l:x i Conl'ol blFFdng rror the eoges ol the
"oo"n-',yror t'om adlacerr bleFde'sr onlv atter vou have
p""f,"r.
i"."""i*"
controlledthe iniuredpodal vern.

'epair o{ the retroparurealicveins However'd

It oossible,do a laleral
liveoatierl' take
you Jno up wiil_a ligated{o/ oversew.])porta'vFir a.ld a
a deep breathand congratulate yoursefi

podalveinconfluence
Transectthe pancreasto gainaccessto the

The root of the mesentery

the bleeding rootof the mesentefy between thumband
Whilepinching
coloncephaladand pull the smallbowel
fore{inoe;lift th-etransverse
to tn" r"t. rhis stretches the mesentery of ihe smallbowel
"-"J"tt"v"na
jtr"n"u"r"" in"i"ionin the serosaof lhe root of the mesenteryand
va."
hematoma to findihe SMA and SMV
care{ully dissectin the mesenteric
de{ineihe injury,andclampLtselectrvely'

lf ihe injuryis immediately ..'l

belowihe Pancreaticborder'
optimizeyour exposureb)/ ..'.)a-.
mobilizingthe ligament ol
Tfeilz or by doing a full
Cattell-Braasch maneuver'
The SMA is exPosed,
allowingyou io Place YoLlr
clamps selectively. Never
clamp blindlyat the root ol
ihe mesentery't ls a reclpe
E ,o, *",rr.n. on & croftofTfoumo
sursery

*:. srvtA;sdi.cussed
inrhererrchaorer.
Repa,. rre
rIU?o srMvrt yoJ "cani i, nor.,;gare:r. Fotlowing
",,T:"J^:,#T" hgalronof Fithert1Fportal
vernor ihe SMV ihe jneviiableconsequencejs
massivefluid sequestration
an^dmidgut,edema, whjchtranslateinto extremelyhigh postoperative
requrrements fiuiJ
and an tnab/lityio closethe aboomen,In iact,
as we wrote
oLisw,rhd souwoJrou"a"*". svv ris;ri";.
l,': :::o]L :oac\
nrs vacLLr l?l'*'"
drdiredib itj tttersoi sero,rst,u;ofro_ rhe p"n-torea,
cavty on lhe fjrsi posloperatjve day. Don,tforgetthat venousgangreneof
'" , oirr ncr rhrear.so
ll: T.y:i bowei atwaysoo a se.ond rook."pa,o-romy ro
ascedarn viabitii!

Blindclampingat the root of the mesenteryis

a recipefor disaster

The pancreaticoduodenal@mple.,
_ ..
Sorie of the mostfascinatingreadingin the trauma
literaiuredescribes
pdlcr.alicoduodena, reDairtech1,o,res, spalrtng d wide .anoFo, verv
rmagr'rai
ve resecironsard recorstrucions. We a.e oa.tjc-la.,y
ioro o{ ihi
opirmisttcii ustraiionof bothends of a transectedpancreas
ptuggedintoa
R-ou\+n-Ytooool oowe,.crFalirgrwo aojacenr
oarcreattcolelJrostom es
lhe prinredpase -oterates
ar,.rhins.lJnfon:rar"ty.
il;"l'J;j"n,."
KFeorhngs as s.-noeas ooss:b.e. €votoacrooaltcs.
,mrred-enu o, sraighifo,ward and st.ck to a
ooLons.yoL wih nor f,1d d detaled
possibte
parcred,icoouooe'la,,ecorsrrucrive
:ll_*'t]". :' "ilastead. rechlrqLes
rT lFrschaoter we giveyoua ve.y| _itedm€nJof s:-p,ea.o sate
Iecnn.q,resthai wo-l ,or rs. T.ree ca-dr,ralorirciple"
shoLtogLioe yorr
approachto proxjmalpancreaticand duodenalinjuries:

1. Dfai. every suiure line in the duodenum

and every signjficant
pancreaticinjury.
2. P.ov'dea roule for Fnlerarteeo:4qoslat to lhe
duooenum,For n,tnor
/rjufles.a raso,elLnajrJbF rs an option.In _ajor 1a--a,
a feedino
, JetLnoslomy provrdesa crlcal nutrtroratsdferyvave, for yo.:rpatteri
3. I\,lostrmoo.ranlty,r,hooseyor_rrepat. tecnn,qJeoased noi on
how
wpt' ,r worhs,bui on how wertit /a,/s(CrapJe,
l)

Chooseyourrepai basedon how well it faxs

 8 TheWoundeclSurgicolsouL

Duodenal injuries
ln mosi cases'
Can vou closeihe injuredduodenumwilhoutiension?
a,simple suiure Justas
lateral
a"ti"iii'i |'"p.i|.of a arodenal laceraijonis
iransversely'even il the
in small bowel injuries,orient your suiure line
!s
lacerationis longiiudinal, io avoidnarrowingthe lumen lf the lacerairon
tio iono,o u u"nsverse repaifwithouitension'do a longiiudinal
,li"i. it"
""fli""" is a matterof personalpreferenceWe usually
"rtur"t""lnique fashion
do a sinqlelayercontinuousrepairin an inveriing

'oopon lhe pancrealic

Tne probleralic wounosare ins'dethe duodonal
aso"alt tt'" watL,wt of the laceralionis difflcult
precisevisualization
"re wall of a struciurers
,qs in other situationswhere the injuredposterior
inaccessible, consrde'openi.1g lhe ouoderLmand teo,ai5glhe iriury
'a n\aw 't!'1
'ron rheirside. u.$:- i'rl '1)1 - r'*
-i-fl +r-- J^**- "'f )
-ore tnan a siraigl^torwardsho'r
Protecl any ouode.1ar reparrr\ar is
l tin" pytorl.
"xclusion
This is good advicefof suturelinesthat
"riur"tong,"niit'"
nlrltiptL, delayed' or appear tenuous Sorne surgeons
aie
dJodenostomyor Dy
decompies. duooenalrepairs etne' by a aleral
parl o{ a 3_IUbe
-""g*0" trbe {romil'e p'o{imaljej'r1Lmas
ano a fe"d ng jeiuroslomy We
svs'emtnat also inclLdesa gastros+omy
"""rt'"n,
-epai's
n'."i ror,in"ruao, *o" duoienosromy br''we drairal'duoo"nal
exlernallywlth a closed suction drain
I t3,,1'4 rh
1si' 3rd and 4th
What if the duodenumis nearlytransecled?ln the
*rts. uo., .av Oe to ca'e{Lllydebndethe duodenalwar' to neathy
"Ore Fno-Io-endaiastomosrs w;th ihe verv r;-iled
;;"r;'"; t;"" do ar
the PancreancsLoe'
mobilitythai you have,it is easiestto beginsewingon
circumlFrence trom wiLl'ir Ihe
;;'ki.; t""; wav arouno the dJooenal
Ihe aohererceoi lhe pancreasand
trrn"n,-Ho*"u",, u" tt'" oLode.1a''oop'
a duodenoduodenostorny'
the proximityof the ampullausuallypreclude

The mosi versatllereconstructive opiion for large duodenaldefects rs

ori,rorrqup a RoL\-en_Y loop of iejJnLfilo repar lhe defpLtor lo re'
]"ru'Jii"".dr"o.ttu'r1, xeeo i' mi,.d'nowevFr' a Rou/-er-Y'euorsirJclion
-Si"""
J,il"-"o*u.ins |."levantonly in a stablepatientwith no otheractive
"td Oodenal traumais almostalwaysassociatedwith
'"Lrr'.".
""""-.
 TOPXNIfETheAri 8 Crolt of TroumoSurgery

other injuries, we use ihe Roux-ef-y technique mostly for delayed

reconstructronsjveTyrafetyduringihe initialopefaiion.
L * N
There.areno good damagecontrolopiionslor
a bad injuryrd rha 9nd
part of the duodenum.lf you need to bail our quickly,approximare
the
edges of a large defect around an externaldrajn to convert the open
duodenur.Intoa controlledJisiula.Thlsshouldbe an absolulelylasi resoft,
since repairingthe duodenalinjLrryis alwaysa much beiter option.

Repairinaccessible
duodenalinjuriesfrom the inside

Pancreaticiniuries

What are the damagecontrol optionsfor injuriesto the head of the

pancreas?For a non-bleedinginjury,the quick and simple solutionis
externaldrainage,convertingevena majorduct disrupiionintoa controlled
pancreatrcJistulathat has a surprisinglybefign naturalcourse.

Bleedingfrom a proximalpancreaticinjuryrequirescarefulassessment.
Once ihe pancreaiicoduodenal comptexhas been mobilzedby a Kocher
maneuverjcofirol bleeding by local pressure, hemostaticsutures, or
packing. Unless the entrfe pancreaticoduodenalcomplex is shattered,
massivehemorrhagefrom a proximalpancreaticinjuryis alwaysfronr an
undeiyingmajorvascuar njury.

Don t fiddle with the pancreastThe classicteachingis to estab|shthe

presenceol a malorpancreaticduct injury.Realityis somewhatdifferent.
lntraoperativeexamination ofthe lnjurywit setoomprovroean answer,and
you are aheadyfanriliarwith our lack of enthusiasmfor oniable
pancrealography (Chaprer7). The truth is thai it probabtydoesnt matter
whetherthe duct is rnluredor not becauseexternaldralnageworks well in

Don't fiddle with the pancreas- drain itl

 8 The Wounded Surgico Sou

concept
Thosewho like playingwilh dynamiteadhefeto the traditional
Io ls perfor-lrg a
of o'pservirq palcrealic tissLe Wnal ir amoJrls Fig,r-rrsl
o"ri"*":."1"1".*".v on a 'rormal pa,rcealic sl'mp a 'or
,"..,..*i" ev.n J.]Oerrne besi eleLllveclrcunstarcesCons:de'
pancreas'where fie
example,the optionsfor lraciure of ihe neck of the
againstihe splne The
ot"na i" tr"n"""t"a by an anteroposteriorinrpact
proximalslurnp'
iafest definitiveoption for this injury is closure the
oJ
the open drstaL
followodby resectingthe disial pancreasor oversewing
oi the stump
st!mp. Analomicalreconsiructionwould meandebridement
loop of
."1 i*ti"g a normalso{l pancreaiicremnaniinto a Roux_en'Y
pancreatic head and a bowel
bowel, in ciose proximityto an oversewn
Wh ile enth y
usiastical
sutureline. lf this sounds unsafeto you' we agree
feports oi what
described in texibooks and often discussed,current
they talk about) indicatethls
surqeonsactuallydo (as opposedto what
i" u",v *t"rv used Apparenily,enoughsurgeons have learned
"pplo".n pancreasdoes not pay
tie oainfullessonthat{iddlingwith the vaumatized
We preferio closethe pancreaiicstumpand drain ii

for trauma
Avoidpancreaticoieiunostomy

Combined injuries
'niuriesto Ihe pancreasard
Bleeo,ngpaiienls with comor,red
_oI de tom a dLodenaleak lh€yersangurrale So slop
a-oden.,m-oo
duodenum' do I
the bleedingand bail oui l{ you can rapidlyclose ihe
and ligaiionio conlrol
Otherwise,use a combinationof externaldrainage
Relurn for a laterreconstruction
Juodenal,biliary,and pancreaiicconteni
if the paiientmakeslt.
divertingthe
Pvloricexclusionls an effectivetechniquefot temporarily
qast'ric away {fonr the iniured pancfeaticoduodenal complex
"ontent nuehavea bias toward ihis elegant procedure we
i"ing e"yrot
"rtg"on",l- -lordan,Jr', who conceivedii We adviseusingt
i""rnl"a tro. e"otg"
injuries
to oroteciduodenaisututelinesin combinedpancrealicoduodenal
is intact
wherelhe duodenumcan be closedand ihe ampulla
 TOPKNIFE
TheAd & Craft of TrournoSurgery

After repairing the

duodenaiinjury,identify
the pylorusand makea
longitudinalgastrotomy
on the antefiorsurface
of the antrum,close to
ihe pylorus. Through
the gastrotomy,palpate
ihe pyloric ring with
your lrnger, gfasp it
with a Babcock clanrp,
and pull it toward you.
Ovefsew the pyloric
ring with a heavy(size
0) suture on a large
needle,iakingbig bites.
We lse a monofilament
suture,but regardlessofthe suturemaierial,
the pylorusopensin 2,4 weeks.
In fact,you canslapleacrossthepylorususinga linearstaplerwiththe same
result,

Once the pyJorus

is closed,brlng up a
loop of proxima
jelunum and do a
gastrojejunostomy.
The Jast siep in the
procedureis pfoviding
a route for enteral
Jeeding into ihe
jejunum.The operation
is noi ulcerogenic,
and vagoiomy is not
part ot it.
 8 T h eW o u n d e c5l u r g i c oS
l oul

slnce Lt
The Achillesheel of pyloricexclusionis ihe gastroenierostomy
this probem' some
cades a significantrisk of nonJunction To avoid
relyrng
surgeonspreJetlo do pyloricexclusionwithoutgasiroenterostomy'
on distalenteralfeedinguniilthe pylorusopens

lines
Usepylodcexclusionto protectcomplicatedduodenalsuture

The "Ultimate Big Whack" ,vf-\

Use
A vaumaWhipple is tha ultimatebig whack of abdominaltrauma
it as a lasi resoriwhen the pancreaticoduodenal complexis destroyedor
solutionwill
when the ampullacannot be reconstruciedand no simpler
a trauma Whipple when the
work. ll is oftensaidihai you shouldconsider ror 'he b g
:nJ1 l^asalreaoydonemoslof lhe d:sseclion you H€rein lies
snatterpd
nlrrao" ot rnis'operariol: tn" e{sangurnalirgpaiierL wlh a
is Loosick to curvrvFit A -tabrepalientwho
i".l,".i""ar.o*a
".rp'ex a lesser akernat've'
Jf .rru,u" n o{Iendoes not need t so choose
howeverimperfeci,wheneveryou can'
 TOPKNTFE
TheArt & Croft of TroumoSlrgery

Thethreeimportant differencesbetweena Whipplefor tfaumaanda

r,arcerar": drssecring
the Lnc,nare
orocess.removrrgtne
lllllp,:,a'
gaIo|adde., andstagedreconskuclion,

a During the resectionsiage for traurna,don,t dissect the

uncjnaie
processotf the SMV and rhe SMA. Leavemosi of it adhefent
to the
S[,lV by dividingit piecemealand oversewingit wilh a runnjngstitch
'or he-roslas,s yoLr
as proceed. Th:s greaty srmpl.fresonF ot the
ticky sleps of the dlsseclior.
a Thinkiwice beforerenrovingihe gallbladderin a traumapatieni.A fine
and delicaiecommonbile duct may force you to use the gallbladder
{orthe biliary,enteric reconshuciion.
a The most importantdifferenceis that a traumaWhipple is a staged
procedure. During the jnitial damage control operation,achi-eve
hemosiasisand do the resection,noi the reconstrLrciion. Leavethe
stomach, jejunum, and parcreatic stump stapled off. Leave the
common bile duct ligated or drained.At reoperation,performthe
arasta-oses,ExceptJrder the mosr,avo,abt€ circumitances. we
reavethF d srdloancreatrcsiumo
slapledor ovFrsew.rand do ,rotjoin
it io the bowel (or 10the stomach)io avoida high-rjskanastomosisin
a cdticallvill oatient.

lf forced to do a hauma Whippl€- do it in stages

Putting it all together

We hopeyou realizeby now why injuries10ihe surgicatsoutdeserve a
specral chapter. The sirategic drmensionof a soul wound is
straightfoMard,sjnceit js preityobviousfrom the very beginningthat you
must operateIn damageconirolmode and dart oui of the belJyas quickJy
as you possrbiycan. The challengeof soul wounds lies in iheir tactical
complexity.You must simplify the taciical situation (Chapter t). Ask
yourselfwhich elementsof the problemcan be rapidlyellminated.Look at
the deep layerof bleedingfrom the IVC and right renalpedicle.Do you
rear'yirte4d to do a como,ervasculdrreoairor rh,sbleedrngrena'pedicle
In the contextof multifocalexsanguination?Of course noi. On ihe other
hand,a swft nephrectomywijl open ihe way to the IVC intury.
 E The wounded Surgicolsoul

as the patLentls
Are you goingto hook the pancreaticstunrpto bowel
*tino'rl"-g+ti u,ril o{ orood?YoL rust be kiodngl A raoid dislal
'eft side of Lhe
pu""r"""t"atotu howeve' may enabreyou to reacn lFe
retropancfeatic Porialvein

Conslantly
Theseexamplesshow you how io simpli{ylacticalsituations-
-
inJUry and go lor
ask yourselfwhal the simplestsoluiionis for a specific
who ihinks
il. The only hope lor a patientwith a soul wound is a surgeon
_ about sprralvern
abour liqaiion,resection,drainage'and shunting noi
graftsaid Roux_en_Y pancreaiicojejunostomles'

Lookfor wavsto simplitythe tacticalsituation

THE KEY POINTS

injLlry'
) Soul woundsbleedlrom moreihan one vascular

) maneuverto exposethe surgicalsoul

Use the Cattell_Braasch

) Ligationis ihe bail oui soluiionfor portalvelnInlury

portalveincontluence
> Transectihepancreaslo gainaccessto the

for disaster'
) Blind clampingat the root of ihe mesenlefyls a recipe

) Chooseyour repairbasedon how well it fails'

) Repairinaccessibleduodenalinjuriesirom the inside

itl
Don'lfiddlewiththe pancreas'drain
>

) for trauma
Avoid pancreaticojelunostomy
E ,o, *",rr rn. * & croftofTroumo
sursery

) Usepyjoricexclusion
to prot€ctcomplicated
duod€nal
suturelines.
) if forcedto do a kaumaWhippl€- do it in stag€€.

) Lookfor waysto simplifythe tacttcatsituation.

 Chapter9
Big Red & Big Blue:
Abdominal Vascular Trauma
..,Lleon?ntering!h? peiloneal .auit!, dpptoximalely2lo
3 tit'ercol blooi, bo!h liquid ond in (lols, TaereencounlerP'l
fi"', i"r" rcnloped. Thc bulle! pa!huaV ,uas- lhen.
idenlified as haoinB shdllereil the upPcr medial s tlo(? oJ
the ,ileen, then cntireil the refuoperitonealarea 7uh?telherc
iii'o torB" rcttop?ritonPal hemalotna in the area of the
(ofiin3
oanrreas.iollozuinp this, bleeding sccmed to be
'ftotn
'bi lhe right side,-an.l pon inspection lherc 'uas scPnIo
on r*it t'oth, ight throtgh the infeioroena 'aua lhe 'e
ihtouph the supe-riorpole-of the iSht |id e!, the louer
iiiiS, A the'rightiobeoi th" liui' and into lhe riSht
'lateflt
b;du wilt'.. rn" infeior oena caua hole was
clamp"' Theinspectionof
iiiip"a wiin a partial occlus1on
lhe ietroperitoical arca reuealetla huge hcthdlomo in the
midline. fhe spleen uas lhen mobilized, as uas lhe I?J1
ond the refuopeitonedl apPtotrchwtts fiade to the
iid-iirc structutes' Thepaflleas 7o4sseet to be shattered
"ilon,
i its mid portion, bleeiling uds seefl to be cotning ftotfi the
aorta.., B'leeilingwas coitrolled by finger pressurcby D,r'
Moleolm O. Peiru Llpon iden!ifintion ol this iniury' the
suterior mesmteir artery ha.l beefisheaftd olf the aorta"'
1ii. uas rla nped wilh a'sna Il (urucd DeBakeyclamp' lhe
aotta was thin occludedTnith a straight DeBdkey clanp
above and a Potts .lafip below. At this poinl all fiaior
bleedins was (o trolled..'Shortlv thcrcafler"' Ihe putse
'was to
role.., found lo bc 40 and a Iew sercndslater Joutld
be zero. No'oulsewas felt in the aoltd at this time'

- OpeiativeRecordoI LeeHa|ve)'Oswald'
ParklandMemorial Ho spital11'/24 /63
Cired n1tThe\Nhren CommissianRepott:REart oJthePresilent's
*zi,:i?::i',;X:,Til;
antheAssas"^"."
canmission "f
 TOPKNIfETheAri & Crofl ol TrournoSugery

and un{orgiving
No authorhasevercapturedthe tremendouschallenge
ihis dry' technical
nature of abdominalvascular trauma better than
a,rd\is ream at Parl'aid do ng
.".",i"" -pott 0""""t''q G To* Sn:res
ilrrt" *i,l'nurpre vascLlarinjJ-ies i'l,le aodomer of Lee Hdrvey
O*"*"fa. ifr" *oon lhs centralleaturesof abdominalvascular
".phasizes
irom inaccessiblesites' muitipleassocated
trauma: massivebleeding
';;,;""..;; un narrow window of oppoduniivto save the
""u"."-tv can also often hear it
.lil""i. v", noi onlv see the bleeding'bui vou
'Because
the patientis exsanguinating, you rarelyhavelime io summona
more experiencedcolLeague to help you gain control You havelo lasten
youf seat belt and gel going.

The "lules of engagement"

free iniraperlioneal
An abdomlnalvascular injury presenis as
hemorrl'aqe,'elropenlo'eal lematonao' n osl co-mo1ly'a uombilar'on
il s a'waysBIG TROUBLEa'd ine keyto sLuces"
o{ botn.In-e'rne'cas".
control{ollowedby a well-organizedatiack The locationol
;;;p"*ry
the hematomadictatesthe operaliveapproach

Hematoma
OperativeApproachto Retropedtoneal

Hematoma Explore? Proximal

control
PenetEling Blunt
Yes SuPraceliac Matioxmaneuver
Midline res

Yss lnlrarenal Infrarenalaorijc

N4idline
aoita or IVC exPosureor right_
sided visce€l rotaton

looping

Distalaorta/
tvc
 AbdominolVasctror rrourio H
9 BigRed& BigBlLre:

Midline suPramesocolichematoma

All midline sLrpfamesocolic

hemalomasmust be exPloredlf
thepatieniis in shockor if Yousee
rapidaclivehemorrhage fromthe
supramesocolicarea, manuall)/
compressthe supfacellacaona
(Chapter 2). lf ihe Patenl rs
hemodynamically siable, begrn
wlth the Maiiox maneuver'The
medialvisceral rctationallowsyou
to gain prcximal control of the
lowefthoracic aota bYcuitingthe
lefi crus of the diaphragm
(Chapier4). AlwaysobtaindislaL
control above ihe aortic
bifurcationbecause without it,
considerableback bleedingwill

and ihe
Iniuriesto ihe patavisceralaodic segmentbetweenthe celiac
renaiarteriesare highly lethal They are alwaysassociatedwith injuriesio
'Blooo
'o"" '" typicary -assive confo' is not
"ii"l".t ".ort"t.and repairreqJiressJptac€'iac
str'ao'rforwarO, ula-ping For althese
reasins, iry to get awaywith a laieral repairil you can'

ll vou mJsr sew n a sy1ll^eLrc 'nte-posiliolg'alt yoL are obvously

ot
racinoaaainstine rela' ischemiclime' ano lhe oalienr'schances
latge'
cligl"tly
n'akin'qiiare not sreai S-"lecta \,littFd Dacrong'ail lhalis
oecaus" the aona ol a vou.lg oaliert rr shocl<r
ir,".,i" aon" a'i."*t
vasoconstricied. Since you have no alternaiive,don t hesitateto put rn a
no enectLvo
orafi even in the presenceof intestinalsPillage Thefe are
'n;ur'es The patrenls only hoPF s a
iumaq" conror op ons fo- thesF
,-i. i"ri"+"" rapai'of the aortaano bail out soutions for associated
Inlunes.

Tryto get awaywith lateralrepairin suprarenalao*ic iniuries

 TOPKNIFE
TheAl-t& Crofl of TroumoSurgery

Pentratingtraumato ihe proximalfenalarteryis essentiallya side-hole

in the aorta. Initia control and exposureare the same as previously
described above. The realisticoptions for definiliverepair or damage
conholof the renalvesselswere describedjn Chapter7.

Injuryto lhe celiacaxis or lts branchesis uncommon,but deadly.

Typically,you see a gastric injury with either an expandinghematonra
behindthe stomachof brisk aftefal bleedingfrom behindand aboveihe
essercurve.This is one of ihe toughestand leastadvertisedsltuationsin
abdominaltrauma.

Wh le you car gain

proximal control of the
celiac axis by rnedial
visceralroiation,this wil
not help yo! see or
controlbleedinglrom its
branches. Furthermor-o,
the operal/ve circum-
siancesmayforceyou to
attack the bleederfronf
the front. There are no
slandard prepackaged
solulionsfor this d tficuli
silLration.A lechnique
that has workedfor us is
insertinga gross hemo-
staiic stitch wiih a heavy
sutureon a big needle(suchas siz€0 polypropylene)
into the lesser
omentumabovethe lessercurveof the stomachand suturingunti the
bleedjng
stops.

A usefulallernatlveis transeciingthe stomachby firing a inearcuitng

siapleracrossthe body,givingyou immedlaieaccessto the vasculafinjury
behind ii. lf the patient suryives, complete the hemigask€ctomyai
reoperation.Dissectingoui the originof the celac axis,encasedin a thick
layerof pefiaortictissue,is not a realisticoplionin a bleedlngpatient.
 vosculorlraur'o E|
9 BlsRed& BisBluerAbdomjnoL

s;t'iafontnatprelpnis
IntLryIo tne p o\rmalSMA 15anothe unlo-giv'ng 'he
.ematomdAn irjLryto sMA dbovelhe
,"':';:;"
";';-"'"colic anteriorhole in the suprarenalaorta ControlI
J *""*'",'t
""*r"* "n the aorta
iror tt'" t"t Uyp"*orming a Mattoxmaneuverand clamplng
"ia" You can then get to the injured
*J oa"* ,i" t"le-off o-fthe vessel
"0""" in the lesser oment!m
SL4A,eitherfromthe side orfront, by makinga hole
pancreas caudally These injuries
and retractingthe upper border of the
wiih damagelo the pancreas and adjacent bowel
are tvpicallva=ssociated
ligation' followed by
Ott"'nyour b""t option*ith a proximalSMA injufyis
retrogradereconsiruction

is achievedby
Control of bleeding from the reiropancreaucSMA
SMA below ihe
dividingthe pancreas (Chapter 8) An injury to the
of the mesentery
parcre-aswill manifestas a largeher'atomaat the root

ng a tenrpofary
The damagecontrolopiion for S[4A injuriesis insert
{orthem
Wt it"i"" t'"u. not done it, othershavereportedit wofked
"lrnt. ano vasoco,rslicted
t ioari,rqt're proximalSIVIAi_ a sFvereryhypotelsive
-o bowel iscl-e-id So \ow
p."t,"nt:. noi gooa op ro' oecaJsF il lFaos
"
shouldyou reconslructlhe SIVIA?

The pinciples are lo use

the most exPedientmethod
andstayawayfromthe injured
pancreas,becausea €aKrng
pancteas and an anerlal
sulure line dont sri welL
togetherTo do a retrograde
reconsvuction from lhe infra'
mesocolic aorta, J/ou need
accessto the side or to ihe
posierior aspect or tne
vessel,Youcan approacnfie
SIMA immediatelybelow the
pancreasand frori the left b)/
dividingthe liganrentof Treitz
and mobiLizing the fourih
portionof the duodenum.
 Ihe Ad & Croft of TroumoSurgery
TOPKNIFE

Alternativey,do a full Caiie lBraasch maneuverand reflectihe small

bowel upwardlo obtaingood accessto the posterioraspectof the SMA
(and
lf you aie not sure how to do it, you can dissectout a more disial
thereforesmaller)segmentof the SlvlAat the base of the mesentery

Reconstructthe injuredSIMAusinga 6mm ringedePTFEgraftftom the

distal aoria or the right com..on liac ariery LJsingthe latter has
advantages:it does not requireaodic clamping,is easy to cover wrh
omentum,and is technicallystaightlorward

the SMAawayfrom the iniuredpancreas

Reconstruct

Midline inf ramesocolichematoma

Eviscerate the small

bowelto the dght,Pulllhe
transversecolon uPward,
andtakea good lookailhe
retroperiionealhematoma
waiilng n the shadows ll
the bulkofihe hemaioma is
to ihe Left of ihe small
bowel mesentery, You
probablyare dealingwiih
an infrarenalaodic injury
thai can be approached
lhrough the midline lt,
however,ihe hemator.als
moreto the right,Pushing
on the ascendingcolon
lfonr behind,you probabLy are dealingwrth an IVC injuryand shoulddo a
medialvlsceraL
right-slded rotairon.

Aooroach aninlramesocolicaorticinjuryasyouwouJda rupluredaortic

aneurysm. retractorand ofganize
lf you havetme, placea self'retaining
theo;erativefieldlo keepthebowelevisceraied andoutof vourway The
 g
9 BiqRed& BlgBIue:AbdominoVoscuLarrroumo

classicpitfallln proxirnalconirol
o{ lhe infrarenal aorla rs
iatrogeniciniury to the LRV or
lVC. To avoid ii, look at ihe
shape and Pfecise locatlon ol
the hematoma.ls ii distal,away
from the root of the transverse
mesocolon?lf so' ihe 'sk ol
inadverieniinjuryto the LRV is
small. Mobilizeihe ligamentof
Treiiz,refleci ihe fourth poriion
o{ the duodenumlalerally,and
enter the safe PedaodicPlane'
Blunily cfeate a space lor a
clampon boih sidesoi the aorta
using Your {ingers However,if
the hematomaexlendshigheruP
obscuringihe ligamentof Treilz'
it will be much safer io gain
supraceliaccontrolihrough the
man!allycompresslrglne
Lesseromeniurnabovethe stomach,eltherby
ot the
the spine or by clampingthrough the tighi crus
".,t" "g"ln"t
diaphragm(Chapter2).

and' using blunt

Wlth proximalconirol in pLace'enter the hernatoma
in the
ai"""iiiJn, oti"nt yourselJto avoidthe LRV Dlssecidistally
".t"turrv your clamps below the
."r-""nt to a"tin"it'" injLrry'Reposition
tfoublesomeback bleedingfrom lhe distalaoria or
i*Jlrt"r,"" "f"*to
"onttot I
tom 'he lLmbarafe'es ard oegn lhe reoa

hematoma
-eware of iahogenicveininjuryin an inframesocolic

lor the
lJn{odunateLy,we cannotof{eryou good damageconiroloptlons
a chestiube as a lemporary
infrarenalaortaeither'We havelried inserting
but did not havea survivor'However'in 1945'
""t,"*" "irrutlons aorticde{eci{rom a
C.i. Hotr", ot Cin"innuiibrldgeda large abdominal
"tluniin
 TheArt & Crofl of Trournosurgery
TOPKNIFE

gunshoi wound with a vltalliumtube secured wiih umbilicaliape The

patientsurvivedand went homewith the tube in place Anolherdesperate
measurefor extremesituaiionsis oversewingihe injuredinfrarenalaorta
revascularizaton if
es, followedby extra_anatomical
and bilateralfasciotom
the paiienisurvivesthe physiological
insu t.

Whai are the definitiverepair options?Unlessthe lacerationis small

and amenableto simplelateralrepair,your besi bel is io grab ihe bu I by
the hornsand inserta short 14-18mmsynthetc nterpositiorgfaft Since
lhe aoria of healthyyoung paiientsis smal and iears easily,at(emptslo
sew in a patch or do an end{o-end anastomosisolten ead io an
unsaiisfacioryresult.We adviseyoLrsaveyo!rself griefand go djfectlyfor
graft interposlionusingknittedDacron.

Alwayscover your inframesocolic vascularsuturelineswith omenium

Our preferredtechniqueis lo lake down lhe greateromentumlrom the
tranverse colon along the bloodless line, create an opening in the
lransverser.esocolonto the efi ol the midde colc artery,and swing the
mobiizedomenlumthroughihis hole intoihe inframesoco ic compartment
to coverihe aorticreconsiruciior.

lf you see a bleedinghole in the psoas muscle,BEWAREIThis

deceptivey simplelnjuryls one of thosetraps not mentionedin the books.
Whatevef you do, don't dig into the muscle in seafch of the source
B eedingin these cases ofien orig natesfrom the ascendingumbarvein
or a lur.bar adery.Thinkof it uoi as a sma I bleederinsidea muscle,bui
asan naccessible sdehole in ihe aortaorthe lVC lnsieadof a direct
aitack, choose anotherhemostaticiechnique:stufi ihe hole wiih a local
hemostaiicagent, pui a ballooncatheter into it, or pack t with gauze.
Whatevefyou do - don t try to ideniifythe bleeder'Yoursmallbleederwil
rapidlybloomintoa ful-scalecatastfophe.

Don'tchasea bleederinto the psoasmuscle

 t' ''t"t E
I8ig Red& BigBlue:Abdtttt'ut't'

The Infedor Vena Cava

A large dark hematoma

behind ihe right colon is a
€ign o{ IVC iniury.This is a
unique sitllation in ttauma
surgery whefe you may
deliberatelyflip a control|ed
situation into unconirolled
calamity. The iamponade
ef{ectof the retroPeritoneurn
may have stopped rne
bleeding,and }/ou are going
lo unroof the injury and
releasethe tamPonade,with
a real risk of makingthrngs
much worse. You betler be
absoluielysure You Know
what you'redoing

Preparefor BIG TROUBLE

(Chapter2), andihen unroot
the hemaiomabY right-sided
medial visceral rotation.
Once you afe greetedwith a
violent gllsh of dark blood,
I gain temporary control oY
digitally comPressingthe
IVC againsithe splne aDove
\ and below the injurY.RaPidlY
delegate the iob to Your
assistaniio free Your hands
fof the repair.DigilalPressure
is effeciive,but the assistant's
handslimit YourworKsPace
We pteief to use tighilY
rolledlaparotomy Padsheld
on ringedclamps Watch ihe
 TOPKNIFETheArt & Crofl of TrournoSugery

palient'sblood pressureon the monitor,and talkto the anesthesiologistlf

the patienicrasheswh le lhe lVC is beingcontrolled,compressthe aoria
as a hemodvnamic adiunct.

The key maneuverin

repairinglargeveinsis to
define the edges ol rhe
laceration. lt js mpos-
sible to see the injury
properywh le the IVC ls
activelybleeding.Youare
looking for the edge of
the Laceralion - if not allo{
it, at east part of it. Look
for ihe s very intimaand
genily gfasp the edge of
the laceratonwith a ong
hemostator a Babcock
clamp and lift it up to
visualize the adjacent
segment. Apply another
clampand hold it up too.
As yousystematicaly work
your way around,you wlll
be abletodefinetheentirecircumfefenceofthe acerationandthencontrol
it with one or two vascularclanrps. A side-bting Satinskyclamp is
particularlyuseful.

Anotherlrick is to insert a polypropylenesuiure ai ether end of the

laceralion and tie it whie yourfingeroccludesthe hole.Gentlypuling
these end suturescaudadand cephalad,respectivey,pullsthe edges of
the ve n iniurytaut,likea rubberband or ihe sif ng oJa fiddle.Movingyouf
occ uding finger slowly allows you to place one suture at a tlrne in a
re ativelybloodlessfield. Beforeyou know lt, the repairis complete.

lf the IVC injury is posterior, inaccessibe, or there are several

laceraiions,deliningihe edgesis much more difficult.When you can see
 g
vasculorlroumo
9 BlgRed& BigBlueiAbclomlnol

or cannotapolyd slde-bililg
tne b.€eoi'1g']olebui ca11oldelile the edge
rwilh r'1lot\F lJmpn
a 3omlballoo,1r
clarp,'n.e-rnga ld'geFolevcatnercr
and inflatingit can helP.

warn you ot a
A hematomabehindor aboveihe duodenalloop should
long Deaver retfactor
cavalinjuryaroundor abovethe renalveins lnserla
compress Ine
over the inferior surlace of the liver and iow ln to
supfarenallVC, while simultaneouslyreiractingthe liver 10
inaccessibLe
and posterior
or*ia" fl.it"O wofk space Expose lhe right lateral
" kidney medially
!"0""o oi tf'" pafarenalIVC by mobilizingthe tighi
you can divideihe proximalLRV wiih to
impuniiy improveaccess
Similarly,
conitol of the IVC
to ttre titt siae ot tle tVC. Ev€nwith these maneuvers'
ai or aboveihe renalveinsis a realtechnlcalchallenge

In IVCtrauma,get holdof the woundedges

and
What are yout repair opiions?lf the laceraiionis straightforward
a complex reparri
easilyaccessible,do a latetalrepair'lf ihe injuryrequlres
you may be
the patientis stable,and you havethe necessaryexperience' -hs favorab'e
rempled to e'gdge il gymnastlcs Unlo4urately'
,r*f ini'r'yir a stabrepaliell wilh no olher
""rno'-,-.'" "".pf"" classic
iniuri"" i" extremelyrare bird, almosi neverseen in natufe A
"n
eia.ple of gy.na.t'ci, an rllJsrraiion yoJ ofienseein boonsa1datlases'
tn'oJqha
'" r"p;, oi,f'" posierio'wa' ol th. IVC fro- Ih€ Inside
reconstructive
tonoiiudinalanierio, venotomy Nlanyoiher neat complex
including
t;;"iqr"" n"* been describedfor high-gradecaval iniuries'
n'ore Allbelorq to a bra"cn ol
Daneora{'s,svnlhelrcgrahs' palches ard
l'".w'r as scielce'icton Thev rdy nave worked fol
ir'r"ir*."'.t"*"*
for you Our strong
someonesomewhere,bui ihey ate not goingto wotk
advice- and we cannotovefemphasize this enough' is to avoidthe lancy
IVC' ligateiiL
stu{f.lf you cannotdo a simplelat€ralrepaifon the inlrarenal

but i{ the
Do your besi to repairihe activelybleedingsuprarenalcava'
consdera baloul solurlo' Pacl''ngmay work _ ll
oaientis,n exlremrs,
is accept:ngthat ihe
nas cerlainlywo-kedlo' us L:gat:on a,rotl^erootror'
on_iableexsang!lnalon
kidneysmaytakea hii' whichis stillfar betterlhan
 TheAri & Croiioi TroumoSurgery
TOPKNIFE

More importantly, if you see a non_expandingsupfarenalhenratoma below

the liver.do not touch it. Leaveit aloneot pack it Don'i poke a skunk.

Ligatethe IVCif lateralrepairdoesn'twork

Pelvic hematoma

lJfless you specificallysuspecian iliac vascularinlury,do not oper a

pelvlchematomain a bluni ttaumapatent wilh a pelvc lracture You w ll
only make matterswofse. lf you tind yourselfJacinga rupiured pelvc
hematomain such a patient,your best moveis to quicklypack the pe vis,
which shoud controlvenousbleeders.Fo low th s with a tapid ter.pofary
abdor.inaL cosureandproceedto angiography fof selectveembolization
of aderial bLeeders,
typ cally smaI branches of lhe iniernal liac arieties.

In a patientwithpenetrating
t|auma, a pelvLcnemaloma
meansinjuryto an iiac vessel
unlessprovenotherwise.You
must unroofthe lnjuryand flx
it. lf the injuryis on lhe right,
mobillzethe cecum;lf on ihe
lefl, mobillzethe s gnroid.
When you can t be sure and
suspect a bilateralinjuty,
doing a full Cattel-Braasch
maneuvergrves you wde
exposureof the illac vesseLs
and keeps all your opiions
open, Now you musi gain
controLof the pelvlcvessels.
Pfoximalconirol is obviously
not enough. You maY have
forgottenthe ntenraliiac
 g
Abclomholvosculorlralmo
9 BigRecl& BigBLue:

afe difficultto reach So

vessels,but theyhavenot {orgottenyou,and ihey
what shouldYoudo?
The technica!PrinclPleis
'
"walking the clariPs
Beginwith globalcontrolIn
virgin terriiory outside ihe
hematomaby clamPingthe
proximal common llrac
artery iogeiher with ihe
underlyingvein.The easiesl
way to achieve dLstal
conlrol is to have ]/ouf
assistanitow in wilh a large
Deaver retractor over the
lower part of the oPen
laparotomywound, globally
compressingthe exiernal
iliac vessels wiih ihe
reiracior againstihe Pubic
bone. Now, oPen the
yoLr
poste-:oraodonila ot oelvic periloiFun' and o''l1lly d ss€ct w th
i']sidF the
inoe, ro q"t Io ll'e lace atpd vessel As you progress
closer to ihe iniury'applyrng
heilatoma,advancethe clampscloser and
your conirol is global and
if'"r-a U.,i' iliac artery and vein lniiially,
proximally
,"mot.. e" you graduallyconvergeon the source of bleeding
ilturrv,'vor i ping becomesmore seleciive Finallv'isolateand
"rut lascular cLamp'a
controLtheinternaliliac ariery or vein usingan angled
"nJ
Satinksyside-bitingclamp, an intralurninal Fogariyballoon'of any olher
methodthat worksfof J/ou
in any
Walkingthe clampsis a generallechnicaprinclplethat applles
and
bifurcates the deep branch is eithef
situationihere an injuredartery
not oirec.tvv-be oiiraccessrb,e Conrro o"ne blFedi,rg'e-ora'anery
-o Lhe
*" o'oi", td'oiid iri|.ries ir ihe lecl and pe,relralrrglra'rma
"
tnorac; outlelare obvroLsexamples wnerFwa '('ng'he ula-ps can save
the day - and YourPatient'sllfe
you cannotbe
With iraumato the aortic or caval bifurcaiionor when
you may have lo do a ioial pelvicvascular
sure which side is bleeding,
 lhe Art & CroJlol TroumoSurgery
TOPKNIFE

isolaiion.Begin wth the Cattell-Braaschmaneuverto obiain ihe wdesi

possibe exposureof the pelvlcvasculature,then proceedwiih clampng
(or compressng)the disia aorta, and insert two Deaver retractorsto
compress both dlstal exiefnal iliac arteres and veins. Now, enter the
hematomaafd startwalkingthe clampsio convergeon the inj!ries _Jirsi
on one side and lhen on the other.Keep in nrindlhai the ureterpasses
overthe bilurcalionof the commoniliacartery,and vour paiieniwi I do so
much betterwithouta transectedLrreler.

Walkthe clampsto graduallyconvergeon an iliaciniury

Traunraio ihe confluence

ol the commoniiac veins
is partcularlydffcult io
coniro because it is
inaccessible, Lyingbehnd
the right common lliac
artery.Lfyou cannotget to
i to inserl a hemostatc
suture,your besl move !s
to iransectthe overyrng
right commoniiac adery
between clamps, givng
you access to the injured
confluence. lf the patient
survives, repair the tran-
sected artery or Insert a

What are your repairoptlonsfor the iLiacvessels?By the iime you have
gainedvascllar control,ihe patienthas iypicaly sufferedriassve bood
oss and has associaiediniuriesto olher abdominaotgans, usuallyihe
co on. bladderor smallbowel.Talkio the anesthesio og sl and assesslhe
magniiudeof the physiological jnsult. Moreoltenthannoi, the siiuationwil
havedamage contro wrltten alL over 1. lf the artety requres on y a simple
l a l " ' a ' e p a ' - j - s _ o o i . l. f r h ei _ j u r iys m o ' ee n e n sv p a t e - p o r c r ys l ' u 1 l
is a classicand effeciiveba I oui ootion.
 9 BigRed& BigBue: AbdominolVoscuor lroumo n

iliao a ery pedorm a

Anolher allernatlvels to oversewthe lniufed
(SlClJ)
i"""i"i".V, *""f, ,le leg in the SurgicalIntensiveCare Unit
""a do a femorojemoral
lfthe patienisurvivesand the leg is grosslyischenric'
evenfor a trip lo
l*u"'" ior"a,or" p"*r"ion lf the patientis too unstable
iiJ on, ti'i" bvpasscan be done ai the bedsidein SlcU
it togi"ti"" u iltLedemandingand the conditionsawkward' but
"t'uigttf.'*ard
""ni" uselul damage
the" operationis feasibleand we have done it Another
a bleedingbullet
contfoltechniqueis to inseda Foleyballooncatheterinio
ihe iniernal lliac
tract deep in tire pelvis lo control hemoffhagelrom
ierriiorythat is not accessibleto direct control

our advrce s
As for definitivereconstructionof an injurediliac artery'
arteryror an
not to wasie valuabletlme irying to mobilizea iransected
just Inierposea
end-to-endrepairbecauseit rarelyworks lnstead'
syntheticgraft.

SpilLage of lniestinalconientis verycor.lmonin iliacvasculaftraumaand

roi a
po""s o dle --a b"car-e irte"li'racorlell a1d-yrlh"ricgrdttsa'e
Tl-is s n fdct sJch a oopuar qJPsllo,t on Boa'd
lood
"o-on"ton io encounierit therebefofeyouface the situation
ixams that you are lit<ely
ihe safest
in the OR.'Whal should you do? For lhe Board examiners'
do afemoro_{emoral
answ"r is ulsoyoursufest;piion: ligatethe arteryand
real li{ewe assessthe
bvoassa{terthe abdomenis closed However'in
bowel content' t Ls
deqreeof contaminationFor limitedspillageof small
graft
..i to fix the bowel,nrigatethe area,inserta syntheticinterposition
swimming In a pooL
and cover ii wth onrentum.lf the injufediliacarteryls
{igureout ihat ligaiion
lf fecal materlal,it doesn'tiake a Googlesearchto
with extra-anatomic oplion
bypassls the only realistic

unforgiving
Do not dilly-dallywiih iliacvein injuries They afe extremely
and youf paiient ls stillalive'
and leihal.1liou havecontrolledthe bleeding
good fortune Don t spoil
uo, l"* ar*ay *"a up a prettylargechunkof
'"u"ru1n
compler -ep€i s ll yoL can li/ l,le inj-'v wth a
no 6v 6i1"rnpr'.q
rno-enl's
.,:0" ,epai'.do it. l{ no'. ,gd.etr-a vFir wilr'oLIa
"i"'rf closea largedeteci
hesliationThe iliacveinsare nol mobile,so tryingto
one smallhole
can put tne repairunaertersion Youfind yo!rself replacing
lhis into lour
wiih two largerones. The nexi bite of the needleconveris
S ,o, *n,r,,n. on & croftorTroumo
surgery

hol€s,andbeforeyouknowit,1hegameisover- you'velost.Thegmartest
movsyoucanmakeis ligatelhe vein,

ShuntingaRdli$lion ar€ the bailout optionsfor iliacarteryiniury

) Tryto get awaywithlateralrepairin suprarenal

aorticinjuri€s.

) Reconstruct awayfromlho injuredpancreas.

theSIV1A

) Bewareof iahogenic
veininjuryin an inframosocolic
h€matoma,

.) . .Don'tchasea bleederintoth€ psoasmuscla.

). g6t holdof thewoundedges.

h NC tr.auma,

) Ligatethe IVGif lat€ralr€pairdoesn't.work.

) Wdk ihe clampsto gradually

converge
on an iliacinjury

> Shunting
andligation
areth€ bailoutopiionsfor iliacart€ryinjury.
 Chapter10
DoubleJeoPardY:
ThoracoabdominalInjuries
A battle is a Pheflorfienofl that alu)ays htkes
place ifi the i nctiorr between tTDo'naps'
- AnonYmous Bdtish Officer' 1914

Where to go {irst - bellyor chesi?

You are in ihe OR preparingto opefateon a 17_year_old kld in severe

was walkingdown ihe street mLndrng
shock.Hls story is very {amlliar:he
and shoi him in the left
his own businesswhen two dudes approached
(especially
chesi.Thesesameiwo dudes pop up fegularlyon the stfeeis
were just
on weekendnighis),shootingpeople who alwaysclaim ihey
show
mindingtheir o;n business Plainx'raysof ihe chestand abdomen
a bullei in the epigastriumso, lhe buLletwent inio the Leftchest' across
the diaphragm, andintoihe abdomenThechestiube youinsededon ihe
noiiceabLy
left is acliv;ly drainingblood, while the abdomenis getting
plummeiing Where do you begin?
distended,and the blood pressureis
Chest or belly?

The clock ls ticking,and yout patieniis bleeding Bellyor chest?

the mosi
lf you are unsurewhereto begln,you are noi alone Some ot
exasperatlng baitlesin traumasurgeryoccur in the iunctionbetweenthe
about
abdomenand chest Duflng trainingyou are likely to hear
mortallty conferences' bul
thoracoabdominaliniuriesat morbidily and
you are in for a small
when you try to ook them up in trauma texts,
Thereis not a on
chapter
single thoracoabdominaltrauma in any
surprise.
cur;entmajoriraumaiexlbook Why? What exactlyare thoracoabdomrnal
injuries?Whai makesihenr so special?
 TOPKNIfETheArt & Croft of TroumoSurgery

A tour of no-man's land

The thoracoabdominalregion, also known as the inhathoracic

abdomen,is a uniqueanatomicalregion.lt extendsfrom the coslal margin
up to the nippiel;neanteriorly,
6th intercostalspacelaterally,
and the tip of
the scapula posteriorly.The region includes abdominaland thoracic
organson both sidesof the diaphragm.

Five visceralcomparlmentsconvergein the thoracoabdominal region:

the ghi and Ieftpleuralspaces,mediasiinum, upperperitonealcavity,and
upperretroperitoneum. Whileyou are workingin one compartment,lotsof
mischiefcan occur in another,A commonscenariohas ihe surgeonand
eniire OR team focusing on the iniiiajlyselected compartmeniwhile
neglecting the others. Rem6mber also, th6 abdominal side of the
thoracoabdominal region containsth€ leasi accessibleportions of ihe
aorta,lVC, and upperGl tract.

Fivecompartments
convergein the thoracoabdominal
region
 tr"*'
lO DoubLeJeopordv:Thorocoobdomino E|

Strategicconsiderations

Approximately two'th tds of patienlswith penetratingthoracoabdominal

followed by
,",rr|"; managedby chest tube drainaqe
needoperative
i.i;";; i;; bparoscopv)Roushlvone-ihirdwill
"t" "r**"t'V
thatthe
iiiJ*""ii"'" notr',
l" andit is inthesepatients
andabdomen'
"r,"",
traps awaii]/ou
ol multicavitary
injuriesare ihe most commanlotn
Thoracoabdominal
ir -ore Ihar onevisceral
*"""l;;:;;"; dearrs win b'|eeoins
";e
:l:ilu.:n;:":31,i^"L1".jlllifi;,""
IoL"" - r*gf, youhaveanassortment
"" soLrces
lromseve'al
tnepatenlrsbreeoilq
*',ala" p-"'"t gut wl_en lhe
you are not nearlyas €fiective Why? Because
o{ bleedins
"i."n.",1"*'r, is sreatl;,acceleratedMultiplesoufces
'*i:
;;";;joil;ii;Jt
lllfJJffi"::l"Ji:
ij:
"im;:ru.*"",""""-"""1j
,r""t o'i"t',t'" th" ope'atve
to damagecontro
I'ne
leld Lotsol wornto do:rol enough
mooe
il J i. vo, .u"t O."laeveryquicklyio switch
HowearlycanYoumakethedecision?

You may be suPrisedto

Learnthat the trajecioryoJ
ihe bulletcan help]/oumake
an earlydecisionto bailout
A bulleitrajectoryacro$ ihe
iruncal midline in a hYPo_
tensive Patieni ls a very
ominoussqn becauseine
major neurovascular bundle
ol the human body (aorla'
vena cava, and splne)ls a
midlinestruciureTherefore,
the likelihoodof a major
cardiovasculatinjurYis high
and so is the modalrty A
trajectory across lne
 TOPKNIFETheA.t & Crott of TroumoSurgery

ihoracoabdomina/ mid ne in a hypotensivepatlent shoutd pui damage

control(andthe possibilityoJa cardiacinjury)foremoston your rnind,even
oeloreyou makethe ncision.We cal a bullettrajectoryacrossihe iruncal
mldine a transaxialinjury.

In a thoracoabdomtnal gunshoiinjury,ihe bu lei has an /mporiantstory

io tell,which is why surgeonswith experenceir peneiratingtraumaobtain
a p aif filmofthe chestafd abdomen,if possjble,beforegoingto the OR.
Theseradiographs,with metalmarkersplaced adjaceft io eniry and exit
wounds,iellyou what to expectand guideyou whereio go.

Every bullet teils a story

Which cavity first?

Whe/riryingto decidewhetherio open the abdomenor chestfrrst,you

face one of the classicdiemmasof traumasurgery,and there arent any
good rulesto helpyou. Evenwith a lot oftraunraexperience,
you wlllbegin
with the /essurgentcavrtyin aboutoreihird of ihe cases,mainlybecause
the chesttube outputis lrequentlymisleading.In somepatients,the chesi
tube outpui actually feflects intfa-abdominahemorrhageentering the
chestthrougha holein the diaphragm. In others,a misplaced,
kinked,or
nor{unctionrngchesiiube crealesa {alserrnpressiofthatthe patientis no
lofger bleeding.Hereare someguideliresio helpyou decidewhereto go

a Be paranoidaboui chest iube ouiput, ii wi ofief ead you astray.

Assigna specifcteammembertomontof tthroughout theoperation.
a After chesi lube insertiof, get a chest x-rayin the ER to see if the
drainedside of the chest has indeedbeen evacuated.
t Havea high ndexof susprconfor peficardtaltamponade.
a lJse focused ultrasoLrnd(FAST). Despite obvious Ilmitatlons,the
FASTexanrination wil ofientellyou ifthere is a pericardialtampofade
or ots of blood in the belly.
a Play the odds. ln a right-sidedihoracoabdominal peneiration,the
mosi likely source of hemorrhagejs ihe liver,so beginningwith a
laparotomyis often a good decision.
 hr!r es El
bdomlnoL
Thorocoa
lO DoubleJeoparclv:

maintainlactLcal
The most impodantadvice we can ofler you is to
begin in one caviiywhile the
*"lUi|',r".Si"l"t"" show that you will o{ien
fact and compensale
mainsourceof bleedingis in another'Recognizethis
_o, i, u, o"i_q vigilaniano rac.rcay lle/b' AuL'vely seFk cl res Il_al
so-"'n ng susio ou. ,s ndpPen ng o'l lhe others'deol Ih' didp'tagml're
a qraoLaJypro'rtroi'rg
,renioiapn ag oroore'srve'yobsuu'r'19your
'
ooe".a'ue'r.ld. A,waysoo p'eparedro cl'argeyoJ'pra- rr id_operator
a;d rapidLydive intoihe otherside of the diaphragm

play Talk io the

Here again, good team leadershipcomes lnto
of
anesthesioLogisiOften a subiLe physlologicalderangemenl
is
theonlycluethathemorrhage on
ongoing lhe s
other de
lnconsistenctls
o{ ihe diaphragm

clues to Bleedingon lhe Other side of the Diaphragm

Unexplained hYPotension
Inappropriaieresponseto lV fluidsor blood
Graiuai in"reas" ln air*ay pressures(signof a hemo/pneumoihorax)
Elevatedcentralvenouspressure(signof lamponade)

Maintaintactical f lexibility

Peeking into the Pericardium

lf you suspecla Perlcardia

ta..ponadeduringlaParotomY,
ihe quickesiway io find oui rs
by doinga transdiaphragr.atic
peicardioiomy.Begin bY
d viding ihe left lriang!lar
lgamentio mobilizethe leil
lateralLobeof ihe liver,whrch
usualycan be foldedupon
ilsel{ and retracted to ihe
right. ldentifyihe diaphragm
in the mldline,anieriorto the
 lhe Art & Croflof TroumoSLrrge./
TOPKNIFE

EG junction,and grasplt with lwo AlliscLampsBe carefulnot to iniurethe

phrenicvein.Incisethe diaphragmand the overlylngpericardiumbetween
the Allisclampsunlilyou see fluld escaping{romlhe pericardialsac lf the
fluid is cleaf, close the hole wiih a heavymonofllamenlsuture ll it is
bloody,pfoceedwith eithermedlansternotomyor lefl anleriorthoracotomy
(Chapter11).

pericardiotomy
Mobilizethe left laterallobefor transdiaph.agmatic

Fixing the diaphragm

Use laparoscopyio dlagnosea diaphragr.aticinjuryin asymptomaiic

patientswth thoracoabdominal penetraiionsLapafoscopyis an excellent
way lo lookfor iniuriesio the left diaphragmor anteriorportionot the rLght
dlaphragm.l{ ihe paiient doesn't have a funciioningchest tube on the
relevantside, insufflatingthe belly may cause a tensionpneumothorax if
thereis a holein lhe diaphragm.Therefote,prep and drape ihe chesi and
abdomen,and have a chest iube lnsertionklt ready before you begln
insufflatingthe peritoneaLcaviiy

Wiih an adequatepneumoperltoneLlm and the paiientt lted head up,

you have a nice view of ihe left side oJ ihe diaphragmand a partral
(anterior)view of ihe right. l{ ihere is a diaphragmticiniury proceedwith
explofaiorylapatotomybecauseyou can t relyon laparoscopy10 ru e ouT
a ho low organ injury Some surgeons repait lhe diaphragm
lapafoscopically if lhere has been an intervalof severalhoursirom Lnjury
and ihe palienthas remainedasymptomatc.

Repairof an acuie diaphragmaticacerations !sualy sttaighifo|ward'

lf ihere is a herniatedorgan ln the chest, reduce il' and see i{ ii is
perforaled.lf you are having diffcuLiyreducing the hernia' incise the
dlaphragmto enlargethe defect a Liitleto solveyour ptoblem When you
are readyto cose the laceraiion,grab the edges with long Allis clamps
and pull ihem towardyou. Use a cean suckerto evacuaiethe pleuralor
pericardialspace above the injury Look at ihe effluentin the suctLon
 hluies El
lo DoubleJeopordv:Thorocoabdomrnol

tubing, ls t clear or can

you iell what the Patient
had for supper? lt the
chest is heavilycontam_
inaied, or f You are
evacuaiinglois of blood
and clot,formallyopenthe
chest to address the
oleural space directly
Wilh heavycontamtnalpn
o{the pLeuralspace, trying
to clean the hemiihorax
throughthe diaPhragmatic
defect is keyholesurgety
It is unsafeand ineffective
- dont do rt.

Close ihe diaphragmatic

laceration wrih a non_
absorbable heavy suture
We Lrsea runningsuturefor
shortlacerations and slmple
inierrupiedsuiuresfor long
ones.some surgeonspreler
horizontalmatlress sutures
or even a twolayer repair.
An impodani technical
principleis to leavathe ends
oJeverysuturelongand use
them as handlesio Pulllhe
diaphragmatic de{ectioward
you. The edges ot a d|a_
ohraomaticde{ect tend io
ne'l ore will l-elpyou
,nue,i,so p.rffingo" Lhelastsntchwher placinglhe
preven breedirgfrom t5e
^"t':""" oooo a'ppos'tronTake large oites Lo
pl'ren'cJessersor ihe p eJra sioe of lhe diaol_raqm
 TOPKNIFE
TheAar& Croft ol TraurnoSurgery

What if the defectis largeand you cafnot approxlmate

it wiih a simple
suture? lf the diaphragms avLrlsedperipheraly,as sometimesseen in
severeblunitrauma,and the paiientis stable,you may be ab e to realtach
the avulseddiaphragmto a rib, usuaLly1-2 ribs above the eveLof the
originalavulsion.When reattachments not an optionand ihe defectis ioo
largefor primaryrepair,a non-absorbable pfosiheticmeshis a quick and
easysotulton,

lf you have to bail out or the operativefield ls heavilycontaminated,

reconstruciion with syntheticnon-absorbabemeshis not an oplion.While
thereis no compellingreasonto closea largediaphragmaiic defectwhen
operatingin damagecontrolr.ode,failuretodo so willlorceyouto dealwlth
an even arger defect at reoperation.The muscularedges of the defeci
rapidlyreiraci,progressivelyenlarglngihe gap.Preventthisfrom happening
by insertrngan absorbablemeshas a temporaryphysicabarriefbetween
the abdomenand chesl.At reoperaion,if the field is clean,the absorbable
meshcan be replacedby a permanenlnon-absorbable prosthosls.

Whenfixingthe diaphragm,pull it towardyou

Opening Pandora'sBox

Thirk iwice (andpossibly

ihree times) beforedeciding
io mobilizethe liver in a
paiieni with a thoraco-
abdomnal ifjury.Youmay be
blowingthe ld off Pandora's
Box. A patientwiih a right-
sidedthoracoabdominal injury
drainng large amountsof
dark bood from a rnedia
holein thed aphragms likely
to havea retrohepatic venous
ifjury draining nto the chest
ihrough lhe diaphragmatic
defect. Going into the
 lO Doube Jeopordy:Thoracoobdominol E
","'t'

is a lethal
abdomento mobilizethe liver and iix ihe hole from below
mistake.lf indeed you are dealingwith a coniainedretrohepairccaval
inrounconi'o'led
rnrurv.lorl w J rosecontainment.converlinglre slluallon
i nd yoJrsellttyirg to sqLeeTe
venor,. h".orrh"g" Very rapidlyyou wi|
the toothpasteback intothe tube

The correctapproachis notio mobilizothe liverand staywellawayfrom

postenor
the bare area.lnslead,returnto ihe chesi and simplyclosethe
will
hole with a coupleof big siitches This simpl€soLution
diaphragmatic
preventthe
re-establishcontainment,keep Pandoras Box closed, and
caiastrophichemorrhage

Neveropen Pandora'sBoxl

THE KEY POINTS

region
Five compaitmentsconvergeln ihe thoracoabdominal
)

) Everybulletie ls a story

) Maintainiactical{lexibility

peticardiotomy
the leit laierallobe for tfansdiaphragmatic
L4obilize

When-rxinglhe diaohrag-,pu I t lowardyou

Nev6ropen Pandota'sBoxl
TOPKNIfETheAd a Croflof TroumoSurgery
 Chapter 11
The No-nonsense
Trauma ThoracotomY
Life is pleasaflt Death is peaceful
It's the fuansitiolrthat's ttoublesome.
- IsaacAsimov

or
lmagineplayinga new computergame The plot takes place In one
morei tve do.ains o|.terrltoriesWhile you'reerpLoring one domain'the
realactionmay well be unfoldingin anothef' Eachdomain has a separate
portal,andchoosingihe wrongportalfor a speciiic game landsyou in deep
iroublefromthe get-go.To makethingsevenmoreinter€sting, ihe gamehas
your game rs last_
a differentstorylinein each terdiory.To top everythlng,
'
pacedand short with no teplays
game'
Beginningio thinkthat you don't wani to play?Sorry' ii s noi a
that
and you have no choice lts thoracotomyfor trauma,an operation
operatlve roller
olien starts as a good case and quickLyiurns into an
coasier,especlallyif you are a generalsurgeonwho does not frequenlly
visit the chesi. The action can unfold in one of more of iive separaie
viscefalcompartments{two pleura!spaces' peticardialspace' thoraclc
outLet,and posieriormediastinum),each accessiblethrough a difiefent
incision.Severalpathophysiological mechanismsmay be at work
simultaneously:bleeding, hypoxia, catdiac lamponade' tension
pneumothorax, and air embolism,each evolvingat a differentpace Gei
the picture?

Where to cut?

Choosingthe corfecl incisionmaywell be yourmostimportantstrategrc

a
decision jn a trauma ihofacoiomy.The wrong incision can turn
siraightfoMardcase into a technicalnightmare'
 TOPKNIFE
TheArl & Crofi of TrournoSurgery

For the hemodynamicaly unstablepatieniin need of a crashoperation,

the utility incision is af arterolaterai thoracoiomy through the 4th
rntercostalspace on the njured side. Ths quick incision keeps your
oplionsopen.Youcan easilyexlendit acrossthe sternumto the otherside
of the chest or go into lhe abdomenwiihout havingto repositionthe
patient. However,flexiblity comes at a prce. Whle an anierolatera
thoracotomyallowsyou to get to all parts oJ the lpsilateralung, tryingto
reach a deep posteror chest wall bleeder or a posterior mediastinal
structuremay be virluallyimpossible.

For a penelratingwound to the rlghi lower chest with hemothorax,

considergoing into ihe abdomenfrst. The liver domnaiesihe rght
thoracoabomnal regon and is, therefore,the most ikelysourceo{ severe
hemorrhage(Chapier10).

thoracotomyin the unstablepatient

Beginwith anterolateral

[,/edan sternoiomyis a good ncisionfor precordia]siab wounds,s nce

it gives yo! flll access to ihe heart and great vessels of the upper
mediasiirum.lts biggestadvantageis extensibilrty;you can easilycarry it
into the abdomen,neck, or alongihe clavicle.lt also providesaccessto
ihe hilumof each lung,but accessto the per pheryof the lungis resiricted,
and the oosteriormediastinum is naccessible.

In lhe patientaciivelybleedingfrom penetratlngtraumato the thoracrc

outlei,you can stumble nto a big lrap if yo! chooselhe wrong incision.
You rnustbase your decisionon an educatedguess as to the sourceof
hemorrhage.lf the patientpresentsin shockwith a arge hemothorax, you
typicallybegin with the ltility anierolateraihoracotomybut nraydiscover
you cannotrepar the injurythroughthis incision. You mustthetrrapdly
extend t (or makea new one) to gel to the bleeder

lf the patieni is not aclivelybleedinginto ihe pleuralspace, median

sternoiomyis a good incislonfor right-sidedand midlinethoracjc ouilet
wounds, giving you access io the rnnominaieartery and rts brarches,
However,it is difficullto get to ihe leit subcavan artery from the fronl
becausethe vessel is intrapleuraland posterior So, in a patientwith a
 TroumoThorocorornv
ll TheNo-nonsense

penetralinginjurYaboveot
belowthe lettclavicle,gain
proximal control of the
subclavian aderyihrougha
high left anterolateraL
thoracoiomy in ihe 3rd
intercosialspace (above
lhe nipple), recognizing
that you cannot fix the
vessel through this very
llmited incision. You will
haveto exposethe lniured
subclavian arterythrougha
separaieincision(ChaPtef
13).

The classictfap door incisionis a creativecomblnationo{ a medran

incision lt
sternotomy,left anterolateraihoracotomy,and a lefl clavicuLar
requiresforcefulretractionto openthe uppermediastinum has a high
and
incldenceof postoperativecausalgialikepain due to siretchingof ihe
you ca1
brdLhalp'e*usard olher le'ves We rpver uqe il because
achievethe sameexposureusing jLlsitwoo{the ihree elementsof the trap
door with much Lessmorbidity

Slable pat.€,llshrde iewer surorises You ^'row your sJ-gica iargel

iiom preopefative imaging,andthis targeidictatesyourchoiceof incision
Extensibilityinto another visceraLcomparimentis usually not a
consrde-aton. Posleror medlasli,ral slruclLrF:sucn as lhe ao'la or
esophagusare approachedthrougha posierolateral thoracotomyat a level
poslerolateralhoracolomy provrdes
correspondingto the injury ln fact,
mediastinum that
such outstanJingexposureof the chesi wall, lung, and
usesit in activelybleedingpaiients,especially the
one o{ us occasionaLly if
peneiralingwound is posteriorand low.

for thoracicoutletiniury
selectyourincision
Caretully
 TOPKNIFE
TheArl & Croft of lroumo Surgery

Anterolateral thoracotomy made easy

Placethe patientsupinewith bolh arms exiended,and shovea roLled

sheet behindthe scapula1o siighilyJiftand mediallyrotatethe operated
side of ihe chest.A double-umenendolrachealtube rapidlyplacedby a
competent anesthesiologislgives you a huge technical advantage.
Workingarounda collapsedlung is a walk in the park comparedwith the
iorture of trying to squeezeyour way around a rhyihmicallyinJlating

Makea boldcui in
the 4th lntercosial
space, In a mae
paiient,this s below
ihe nipple. In a
female, retract the
breasi craniallyand
makethe incisionin
the inframammary
Jold.Avoidthe buk
of the pecloralis
major by placingthe
incision immediately
belowit.

Thinkof this operaiioras ihe thoracicequjvaleniof a crash aparotomy.

Work quicklyand deliberaiely. This is not the time to be minimallyinvasivo
or go huntingfor stray erythroc).tes with your thunderstick. lust grab a
kn fe and go into the chest.Carryyour incisionfrom lhe sterna borderto
the midaxillaryline, foLlowngthe intercostalspace in a sLightupward
curve. Laterally,you soon encounterthe law of dim nishingreturns:the
furlheryou extendyour incsion,ihe rrloremuscleyou haveto cut w th less

An experienced surgeoneniersthe chestwith threebold strokesof the

knife:theJirsldivideslhe skinandsubcutaneous tssue;the secondcuts
through the pectoralisfascia, the pectoralismuscle anteriorlyand the
serratuslaterally;ihe thifd is a shortincisionin the intefcostalmusclesthat
brrngsyou intothe pleuralspace.
 g
rhorocotomv
TraLrmo
rr TheNo-nonsense

Grab a knife and dive into the chest

Once you have cfeated a

window inio the P!eufal
space,feelfor anyadheslons
beiween ihe lung and the
chestwaLl.lf the way rs clear,
take a pair of heavy MaYo
scissors and boldly cut lhe
lntercostalmuscLesalong
your line of incision lnserta
rib spreaderinio the incision
wiih the handleioward the
axilla;oiherwise,the handle
wilLbe in yourwaywhenYou
try lo extend the incison
your work
acrossihe sternum,open lhe ib spreadercarefullyto create

lf necessary,extend Your
incisionto the othersideofthe
chest by cutting across lhe
sternumcleanlyusinga Gigli
saw, an oscillatingsaw, or
bone cutters,When crossing
the stemumfrom left to right,
carry the incisionuPwafdto
lhe 3rd intercosialsPace to
stay above the right niPPle,
exPosure
thusiacilitaling ol the
upper mediastinalstructurcs,
especially the innominaie
bifurcation.

The classicpidallin anterolaiefalthofacotomys failureto identifyand

the
ligate the transeciedends of ihe internalmammaryarlery When
patienils hypotensiveand vasoconstricied,this deceitfulartery seldom
 TOPKNIFE
TheArt & Croft of TroumoSurgery

bleeds.Afteryou closethe chest,it soonmakesits presenceknown.lfyou

don t tie the ilansectedends,you guaranteeyour patientan earlyreturnto
the OR.

Don'tforgettheinternal
mammary it won'tforgetyou
arterybecause

Once inside the chest

ln mosttraumathoracotorfiesyou will not havethe befefrtof a double-

l!men iube, andthe anesihesiologist will not be ableto drop the lung upon
request.With the lung inflated,you in tialy see ltUe excepta rh,,thmtcay
bulging balloon and blood arolnd ii. To explore ihe chest, you must
mobilizethe lung.

The key maneuveris

cutting the inferior pulm-
onary ligamelrt. Gently
placeyour non-dominant
hand below the lower
lobe of the lung, pull it
cranially to putthe nJerior
p! monary r gament on
tension,and divideit with
scissors, Rememberthat
ihe ligameniends at the
in{eriorpulmonaryvein, and
a laceratedpulr.onaryvein
may bring your operaiionio a speciacularprematureend. Now, you can
retracithe ung and wofk aroundii.

Mobilizethe Iungby cuttingthe inferiorpulmonaryligament

Evacuate
the blood,askthe aneslhesiologistto stopinflating
ihe l!ng
for a rnoment,and rapidlyassessthe situation.
Whereis the bleedrng
comingfrom? Lufg or chest wall? Do you suspecia perlcardial
 g
Troumorho'ocotomv
ll TheNo-nonsense

umoonade?ls therea mediastinal hematorna?Brighi fed bloodpoolingin

a mixtureof
iie'chesi is frequenilyfrom chest wall bleeders,whereas
bloodare
bloodand bubblesusuallycomesfrom lhe lung Gushesof dark
indicates
the hallmarkof a pulmonaryhilar iniury'Mediastinalhematoma
potenl.al A burqing
|a 9e vesse'rriury. telsP pe icaroiJmis a lamponade
packng
r.rntilprovenotherwise.Oblain iemporarycontroloJ bleedingby
the chesi wall, manuallycomPressingthe pulnronaryhilumof a massvely
Once
bleedinglung, or openinglhe pericardiumto releasea tamponade'
decide whether you are
vou have temporaryconlrol of hemoffhage'
lealing wiih BIG TROUBLEor a smallproblem(Chapier2)

Are youworriedabouithe otherside of ihe chest?Youcertainlyshould

the olher
be becauseyou cannot see ii Any doubts aboul bleedingln
pleural space (eg suspicioustrajectoryor unexplainedhypotension)
the
should prompi you to push your hand immediatelyanterior to
poricardium lo crealea windowiniothe olher hemithoraxls blood pounng
out of your window? Can you scoop up blood and clots when you push
your hand into ihe lateralrecessesof the pLeuralspace? lf so' you riust
exploreihe olher srde

you
Nexi, opiimizeyour work space ls your incisionadequateor do
you can divide the costal
need beiier exposure?Using bone cutiers,
the tib
cartilageo{ ihe 4th rib at the upper edge of your incisionto allow
as much
spreaderto open wider' l{ time is criiical,open ihe ib spfeader
rib cracking This ls not an eective
as you have io, even if you feel a
whatever it takes li
iho;acolomy,and you must haveadequaieexposure,
all thjs is siiil not enaugh,the ace up yoursleeveis, ol course'a clam_shell
dn
e,(renq'orac'ossthe slFrnurnIhdrwlll exooseevFrylh'nglt rs l_oweve-
incislonihai carriessignificantrnorbidiiy

You may wish to do somethingaboui the lung ihat is rhythmically

billowingi; yourface You can ask ihe anesthesiologisi to reduceihe tida
volumeio enableyou to work aroundthe lung, or you can help push the
'mainstemnring' is
endoirachealiube intotha contralateral bronchus This
mrcl_easer on the nglt atnoughlhe dgl^I Lpoer looe may'emain'o'_
ventilated.On the left slde, i is difficulito blindlypush the tube lnto ihe
n'ainstembronchus Ercnangilgar endottachearllbe {or a ooLble_lu-en
 TOPKNIfETheArl & Croft of TroumoSurgery

tube n m d'operationis difiicultand dangerous.Consider it wiih much

apprehensionand only if nothingelse works.

Optimizeyourwork spaceand dropthe lungil you can

Opening the pericardium

A classic errof of inexperienceis leavingthe pericardiumunopened

becalse ii looks okay from the outside.Wth ihe pericardium,what you
see is noi what you get, and a normalappearirigsac can easilyhide a
iamponade.Dlring a lefi anierolateralthoracotomy,retraci ihe left llng
posteriorlyio expose the
lelt laiefal aspect of the
pericardium.Pinch it with
your lingerc to tent il up
and make a nick wiih
scrssorsanienof to the
phrenic nerve. lf you see
blooddrainlng throughihe
hole, widely open ihe
pe,cardiumby slidingthe
s ighily open scissors
parallel io the phrenc
nerve,and deLiverthe heart
intothe open chesl.

lf you fnd blood in the pericardialsac during a right antefolateral

thoracotomy,immediatelyexiend inlo a clam-shellincision.You cannot
properlyexamineor flx the injuredhearlfrom the righi side.

The closed pericardiumis an enigma - open it!

 -ho,o.otolv
1r T.e No no e-.F i'oJ1o El

Conholling the PulmonarY hilum

controlof the
Massivebleedingfrom a centrallung injuryrequiresswift
'doomsdayweapon' because it is poorly
hifu..-ftiht. is a
"t"tping
tor"rut"a fy put,.niin l{ you can stoPthe bleedingby any other
"hock hemostaticsutufe'or rapid reseciionof
"^" a"*"f pressure,
a""n",
"u"f'
ihe injuredsegment- dont clampthe hilum

Youcan'tevenbegin
to encirclelhe hilum
unless the lung is
mobilizedbY cutting
lhe inferior pulmonarY
ligamenl.Ask ihe anes-
ihesiologisi io stoP
ventilatingthe lungs
momentarily, andgaiher
the partiallY-inflated
lung in )/our non_
domlnanthand like a
bouquet o{ flowers
Negotiate a Satinsky
to tne pn'eri!
clai,p arounotne eni're hi'um laking cate 1o avoid Inrury
*li"f' :s ararmilglyc,os6 Pulmora'v hilar Lla-1Pingrequrresbolh
""."J, guides the jaws
luna"; on. f'"na loldsl'ne open clamp while the other
aroundthe hilum.

Clamping the hilum

withinthe festrictedwork
space provided bY an
anterolaleralihofacotomY
can be trickybecauseYou
often cannoi see whai J/otl
are doing. There is a
sinrplerway to do it You
can tlvist ihe lung around
the hilum- ihe Pulmonary
hilar twist. Insiead ol
trying lo negotiate an
 TOPKNIfETheAd a Crofi ol TroumoSurgery

openc amparoundthe hilum,simplygrabthe mobiljzed lungwith both

hands,holdingihe apexof the upperlobeand bas6of the ower.Now,
twrstthelung180'so thattheapexof ihe upperlobeabutsihediaphragm
and lhe baseof the lung is now wherethe apexfesrdeduntila few
secondsago. Bleedingsiops inrmediately. You may needto placea
laparotomypadin theupporpleuralspaceio keepthelungin ihe upsde-
downposlton.Thisquck and simplemaneuver is particularly
uselu
duringER thoracotomy, whereexposure and workngcondiiions are
severelVcomprorlrised,

Twistthe lungto rapidlycontrolthe hilumwithouta clamp

Aortic clamping
The descendingthoracicaorta s flaccidand pulseless,easiy mistaken
lor an adjacentllaccid pulseess tube, the esophagus.Clamping lhe
esophagusdoes not improvethe palients hemodynamics one bit.

Placinga camp on the descendng thoracc aortaduringan urgent

anterolateralthoracotomyis guidedmostlyby palpationratherthan direct
vision.Relractthe left lung anterioryand s ide your handon ihe posteror
chestwa lfrom lateralto medial,fee|ng the concavtyof the posteror ribs
as theyarch towardthe sp ne. The first tubularsiructureyou feel aga nst
the i p of your fingersis the aorta.You can eiiher manuallycompressii
agarnstthe spineor placean aorticclampacrossit freeingyour handfor

The key to succ-

essfu clampingis io
open ihe panetal
pleura.lf the media-
stinalpeuraoverlyrng
the aoria remarns
Intact,yourclampwill
slide off and wiihout
obtaininga purchas,"
 gI
Tltt'.]t"t.trtv
TraLrm.
I I TheNo nonsense

the aoda' ellherw th

Makea holein the parietalpleuraon both sidesof
ccis\ors.A ' yo- 'eFo is a rimreoooe ri'rg usreloLgh
vourI nop.o' N4dvo
q
io.c.o'mmooaLe,cta-p o'reac'r de o' tnFlrac'd tJbe MoreF^lersi{"
itsef' making
dlsseclionmayavulsean intercosiavesselorirjure ihe aorta
maiiersmuch worse

You can't clamp the aorta over intact parietal pleufa

The "turbo" version

Theturboversionof a thoracotomy for iraur'a is ihe muchadveltisedER

thoracotomy,a heroic operailontvpcally begun in the
(or resuscitative)
To b-'gin a
shock room but, l{ successfu,aways concuded in the OR'
thoracotomy,a you need is an endoiracheal tlbe in place'a
resuscitailve
steadyhand,a decentkn fe, and a brarnIn geaf

TLlh Ihe pdlie_-' "tl ar- o gel t o'rl oi yoJ- $av na'e
"ooucl Jei-yis
,o-eor. rqu 't od ne on ro lF L',les- a_d-_'r' cuili_gW're
needlesare
not a centralissueher€,yoursafeiyis Sharpinstr!mentsand
promlnenilyin play during resusciiativethoracotonryA cardrna ruLe'
iheretore,is to haveonlvone par o{ handsin ihe operauve field yours'
siicksand cuis are a clearand Presenldanger In lhe organrzed
AccideniaL
chaosol a resuscltaliveihoracotomy,and paiientsw th penetratng trauma
often carrytransmisslble diseases Don t klll yourselfor injurea co league
whiLetryingto saveYourPatleni

ihoracoiomyis a classicdamageconiroLprocedureAtter
Resuscitaiive
youopenihe chesi,onlyfivemaneuvers are donein the ER

The Five lMovesof ER Thoracotomy

lncisethe inferiorpulmonaryligamentto mobilizethe lung

Open the pericardiumand slaple(or sutufe)a cardiaclaceraiion
Performopen cardlacmassage
lung
Clarnpthe pulmonaryhilumor twist a massivelybleeding
Clamp the thoraclcaofia
 TOPKNIFETheArt E Crofl of TroL,rno
Surgery

lf the palienisurvives,do everyihingelse in the OR. lf oroanized

Flecilicar
activiydoesnot retLrnw hin a reasoraole oeiod; iime.
recognize failureandstop.Dont endanger yourteamin futilesituations.
Regardless of yours!rgicaltalentsandexperience,
youwlllnothavemany
survivorsof resuscitative
thoracoiomy.

Worryaboutpersonalandt€amsafetyin a resuscitative
thoracotomy

Median stelnotomy

Make a verticalrncisionif the

sternal r.idllne exiending from
2cm above the siernal noich to
3-4cm below the xiphold.
Deepen your. incisio. io the
anterior iable of ihe slernum,
keepir,gto the midline.Define
the superior border of ihe
manubrium and blunllydevelop
the retrosternalplanefrom above
with your finger.Then, go to ihe
nferiofpartof yourircisionand
open the I nea alba lmmediatey
caudal to the xipholdio bluntly
develop ihe same plane from

Ask the anesthesiologist io stop

ventilatingmomentarily,divde the
siernunrin the midlineusing a
verticalsternalsaw. Hook the toe
of the saw beneath ihe siernum
and pullon ii io elevatethe boneas
it is be ng cui to reducethe risk of
iatrogenc injury to substernal
siructures.Use the cautery to
con?ol oozingfrom ihe cut edges
of the bone. lnseri a sternal
 Thorocoiomv
Trouma
r TheNo-nonsense El

retractofand graduallYoPen
it wiihoui cracking the

What Youare lookinglor rs

ihe left innorninateveln, lne
gatekeeperoJ the ihoracic
ouilei. Exiendingacross the
anterioraspectol the upPer
mediasiinum,it is lhe lrrsl
structureYou have to deal
wiih when dissectingrn the
thoracicoutlei ln the trauma
sltuation, identify, clamP,
divide,and ligatethe vein

. |"ft in-.in"t" of the uppermediastinum

u"in is the gatekeeper

Closing the chest

to choose beiweende{initive
Much like lrauma laparotomy,you have
lubes In
t".por"ry o{ the chest ln eilhef case' place chest
"nJ "to"r,"space or ir tne medrastinum ano irspecl lhe cl_est
r"^ oleurar
"nerated rlernal Tammarvbl'eoFrs
wa', carefrrlyio' nrercostalmJscLlar'and
lt is a validoptlonwhen
When shouldyou considertemporaryclosure? or
the patenls raoidrvoete'iorat'ns ohvsio'ogv
,"" ;; ;"1";;n"'"t' pacrs or pe'{o-m
i^,i- *, a rerurn to thp cl'esl to re'novF
",!"a 'ne cnesl meansapp-oxlmatng
r""^'*. Tempora'yclosure or
".*,t',1" dnd Lheslwal
tt" to achieveai-irgntcosure 'eavng t,re'ibs
""i" "|<'" You"can rapidlyclosethe skin edges with eiiher
.rl"i"" ,""oor*^""a clips Rarely'
towel
fl"*y .*o{ilament suiureor a serieso{
"""ti**" and will noi allow even skrn
"wien the heart is swollenand edematous emPty
nclsion'we iempotarilysuture an
ot ."di"n
"te'notomy underlying sternum
"ll",rr"
ri"""""""
" riria bag lo the ;kin edges,whilethe
of the plasticbag closure
,"."in" oo"n This L ihe thoracicequivaleni
describedin Chapter4
E ro, *",rr,n" on & crqftofTroumo
su,sery

Skin-only closure of an anterolaieral ihoracotomy

has one big
drawbacl: i, brFeds Wh,Jerraking rhe ;rcrs,on,you
ryprcalryojvrde a
sLDslarttatmassof chestwahmusclesin rherateralpa.r ol tnerncisror.
lf
you don't approximate
this m!scle mass,you will haveconiinuousoozino
iniosignificani
ongoing
btoodtoss,especia
y ii thl
111-l"l ]'Tq"
parent rs coagutopathic.

Formal closure of an anteroJateral

ihoracotomyis straighifoMard.
.
tl" '* usinsrs6yye"r,"o","|su,u.es
tor,owed
oy rayered
1ll.:: T,"::
crosLreot the chesrwdllrLscres,lasctaandskin,h c,osing
a c,am-s\el,
*'e topreciserv
reapproximate
thedjvided
sternum
li"llir'J;1,,5i?il"

THE KEY POINTS

) Beginwith a/.rierolaterat
ihoracotomyin the unstabtepatient.

) Carefullysetectyour incisionfor thoracrcouuetinjury.

) Grab a knifeand dive inio the chest.

) Don'tfofgetthe jnternalmammaryarterybecauseit won,tforgetyou.

) Mobilizeihe lung by cuttingrhe inferiorputmonarytigamenr.

) Optimizeyourwork spaceand drop the Jungri you can.

) The closedpericardiumis an enigma- open rl

) Twistthe lungto rapidlycontrolthe hllumwthout a ctamp.

> Youcan't clampthe aortaover intactpanetatpleura.

) Worryaboutpersonalandteamsafetyin a reslscilatrve
thoracotomy.

) The lefi jnnominate

veinjs the gatekeeperof the uppermediastinum.
 ChapterL2
The Chest:Insideand Out
e'perteflce'
Good iudgmelll cofies t'rcm
i, prri ir"i, ot f 'o ttl Poor i udgne n I'
"
- Arthur C. Beall Jr',MD

for a gunsholinjury
Youareinsidethe righichestdoinga thoracoiomy is .,'oibr'edi's'
ro seethe rLns
Youa'e rerreved
'" ;: il;';;;;;";t wal" P'obabrv
il,.it '"iit* '" -' rs lromtnebullell-olcin tl^echesl
ll roo(s kea,si.nple p,'""".r""1j::i,"""j#"ri;^:
i"i """,y.
". ",","""t"
hemostancsttch Then'as you ky to gel to rr you '
graduallydawns on
1"."""J" 1""""""" oehi;d the diaphragm'it
ihingsare far ffom simPle
your{ace' you can barelyseeihe
Wiih the lungrh}thmicallybillowingin thoracolomy
an anterolatefal
or""l". iu"" ,itou ao' gettinglo it through
ni",ni""."tri'*i.pos-srure Wnen vourinattvfl""t?iJilJ
you cann( ['il1i:
a frgureof I stltch,you discover
'bs lhe ilrercoslal-pacerslu5r
n"""d'"b"""r"" yo, k""o bu-p:ngrrlo
;;;l; a rul'swinsol Ir'ereedle Welcometo
";;;"'; """"m'odate
the big leaguesl
underrated iniury_oneot the
Youhavejustcomeacrossa notoriously
lt is certainlynot the only one
"lial"n .on"t"r"" of traurnasurgery
;;ffi il";;, "i*i "f:*ti";";1"*:"ry"13i$,:1,",,i,
(Chapter5), a bleedinghole in ihe psoas
n
extremitv
i;;; i" ;i" rower ":::"]:.:"1'1" ;;#:1
good 1""il:"".i:i::l"j
TheJa'enot"t o'_T1:'."-1ldo.*,d
"xd-pl€s
souland mayseemslralgl ar ri,srgrarue.Bur
to lhe surqical
you-a'ein deeperwatersthanyou
*nl" r", iru. *". - yo'rdiscover o{ Lrauma
thouq,1t,somotime. wel,overyoJ'heao Thel^iddermo'1slert
yotrlo Lome up w ln
,uil"orl oo",a,t" anoimag;narol{orcing
"'"",iv;ty
unorthodoxsolutions
 TOPKNIFETheArt & Croft of TrourroSurgery

Bleeding from the chest wall

Theintercostal andinternalmaramaryarteriesbleedfuriously
because
,
lhey havea bidirectional bloodsupply.To achieveetfeclivehemosiasis.
yoL mJsl conlrortne arteryt-ombotns,des.The
cnalrengingchesiwati
o'eeoer,'snot tl.e one localed-maoiatelvbenFath your;clio^ s.a,,.g
you n lne'acewheryouopenthechest.h is thecunlrrg.Lnreachab,e
Injury,veryhighor very/owon the cheetwall_a bJeeder youcan bareJv

Yourfrrstpriorrtyis temporarycontrol.Raproty
assessthesituation: car
you see the spurtingvessel?Are you dealingwith a discretearterv(rn
pererrating
trauma)or wrt"d,f,useoozrlgf.omextensrve traLmato ciest
wallmuscles(inblunttrauma)? Are the adjacentribsfractured?ls ihere
morelra'ronesou.ca orb eedirg?Depeloing o.ryor,r,indr1g..
co_p.ess
tneoreederw.tl your.inger,clanp ii, or tempora.'ty
packir.

Next, optimize your

exposure.lf the bleederis
very low or very highon the .---
chestwall,you may haveio
maKe a new tower (or
higher)incisionto get io it.
A n€attrick is to movetwo
intercostal spaces up or
downthroughthe sameskin
incisionand re-enterihe
chesi through a more
appropnatermercoslaspace,
g vingyourselfa bettershoi
at conirollingthe injury.In
somecasesyou mayneeda

Now, choosean appropriate hemostatic technrque.lf the bleedino

vesselis righrinfrontof yoL.s,r1pyctampa,rosr,rure-.igate rt.Th:si,
usuallypossiblewith the internalmammaryartery becauseii runs
perpendicularto ihe ribs and is relatively
easyto reachin its anterior
locatron.A transectedintercostal arteryjs more chailengjng. lt often
 l2 The Chesi: Insideond Ouf

retracls in belweenthe surroundinginiercosta rnusces and requres a

blindhemoslaticfigure of I suture.

The secrelof success

is noi only choosingihe
correcl needlestze, but
also orientingthe needle
paih to be paralle - not
perpendicular to the
adiacentribs.Thereis noi
enough space between
the ribs to accommodate
a fu I perpendicular
swirg
of a large neede, so
unless you drive the
neede parallelto the ribs
you won t be able io
complete ihe arc and )"'
extractit.

What shouldyou do if the henrostatcsiitchdoesnt work? Hefe,a little

tactical creativitycan go a lorrg way. Consider using hemostaticmetal
c ips. Alternaiively,
if the mnedlaielyadjacenirib is shatteredirio several
fragments,rapidlyresectlnga fragmentadjacentto the bleedingvesse
can give you valuablespacefor r.aneuvering.

lf all else lails, take a

heavymonofameni sutlre
on a large needle and
encircle the entire rib
inrmediaiely cephaladto the
bleedingntercostalvessel,
igaling the neurovascular
bundle en masse and
compressingit againstthe
rib. Do it both proximaland
dislal to the bleedlngsiie.
Postoperalive intercosial
nelralgia is an acceptable
prlce for this lifesaving
 TOPKNIFETheAd & Crafi of TroumoSurgery

Another last resort techniquethal works with large bleedingcraters

trom high caliber glnshots rs baloon tamponade.Insert a arqe Folev
ballool carheterlhrougrihe niss,'eracr f.or oJlsideir-o the ch"sL,
nflatethe balloon,and pull hard to tamponadethe bteeding.Ctamp ihe
Foleyflush with the chest wall to maintainiraction on ihe catheier,and
suturethe clampto the skin to preveniaccidentaldislodgment.Leaveth s
compressingballoonin placefor a few daysto ensurethrombosisof the
iniuredartery.We have also stuffed bleedingbullet tracts in the deep
posteriorchest wallwith local hemostaticagentsor bone wax, much like
we do wiihthe hosingveriebralariery in the neck(Chapterj4).

A most ffustratingsituaiionis diffusemultifocaloozrngfronr extensive

damageto the chest wall, wiih mu t ple assocated rib fractures.D reci
hemostasisdoesn't work, and you rapidlyreallzeyour ony opton is io
conirol obvious arterial bleeders,pack the damaged chesi wall, and
rapidlybdilout.T-F"e are oftanlerhaliniLries.

Suture intercostalbleeders parallelto the nos

The injured lung

Despiteobviousanatomicaldifferences,the bleedinglung s strikngly

similarto the injuredllver In both organs,you deal with peripheraliniurles
usinga varietyof hemostaticiechniques,whileceniralinjuries{closeto the
hilum)are verybad news.In both lungand llver,surgeonsuse hitarcontrol
and non'anaiomical segmentalreseciionbut are wary of Jormalextensive
resection (lobecionry n the /iver, pneumonectomyin the lung). The
concept ol tractotomy,a most usef!l iechniquefor ihrough-and{hrough
lung injuries,was originallyborrowedfrom hepatictrauma.

Yo! can suture superficialpulmonary lacerations,but your most

effeciiveweaponin dealingwith the bleedinglung is sfaplednan-anatomic
resecllon.How s il done?
 rZrneChesi:
rnslde
onctOut @

Define the precise

locaton of the injury and
use a linear cutting
stapler to rapidiy open
the inteflobarfiss!re, if
fused.Now, takea good
look at the injuredlung
segment and plan your
lineof reseclion.Youraim
is to remove ihe injured
trssue with the east
amount ot surrounding
heaithyparenchynra. Have
a I stapers and 3:0 or 4:O
poprypropyrenesutures
readilyavaibblebeforeyou start.Ask the anesthesiologist to momentarily
deflatethe injuredlung. Use eiihera wide inearsiapler (60 or gomm)or
several applicationsof a linear cuttng siapler to resect the injured
parerchyma.lf lhe stapledlineof reseciioncontinuesio ooze or leakatr.
underrunit wilh a cont nuousmonofilarnentsut!re.

Pulmonarytractotomy
rs a an elegani lung-
sparing solutton for
t h r o ug h - a n d ' i hr o u g h
penetratinginjuries ihat
are too deep for a
slapled reseciion.The
underlyingprincipleis to
lay open the tract so you
can gei to the bleeders
insideit. In oiher words,
you connectihe iract to
the lung surface by
dividingthe br dge of
nssuebetweenthem.
 TOPKNIFE
TheArt a CroftofTroumoSurqery

Inserlone arm of a l/near

cutiingstapler(we preferio
use a vascularstaple load)
into lhe missile tract and
applythe oiher arm to yo!r
chosen target sudace,
C ose ihe siaplerand lire it,
layifg the m/ssileiract wide
open.Now,carefulyjnspect
I for beeding vesse]sand
suiure-ligate
ihem selective y
using4t0 polypropyene. Do
not closethe traci,

lf yo! don i havea lineafcuitingsiapler,you can do the sanretractotomy

betweentwo iongaorticclampsappjiedto the bridgeof trssueoverlyingihe
missiletract.Afterselectively
co.trollingbleedersin the openiraci, underrun
eachaoriicclampwiih a 4:0 polypropylene sururebeforeremovingii.

Pumonarylractoiomyworks so well ihat you shouldconsiderusing it

evenin deep penetratingwoundsthat are not through-andthrough (i.e.no
exitwound).Inseria fnger inioihe mssiletractand assesshow mlch
uninjuredlung parenchymamlst be crossedto completea thro!gh-and-
ihrough tracl. lf ihe dislanceis short, use the stapleras a ,missile,to
completethe lraci, pushng ii throughthe tract uriil the iip emergesfrom
the otherside of the lLrng.Partoi the tract will be iatrogenic,but a ?aci is
a tfaci, andthereforeamenableto tractotomy.Lay it open and suture-ligate
individualbleeders.

Pulmonary
hactotomyis a neatsolutionto a ditficultproblem

BIG TROUBLE with the lung

Centrallunginjuries
aredeadlybecause theyaredifficultto controJ
and
repairTheyare classrcexamplesof Blc TROUBLE(Chapter2), where
orgafzingyour altackand yourteam beforejumpingin can makean
enormousdifference.
 l2 The Chesl: nslde ond Out

When confronted
with massivebleeding
from an lnjuryclose to
the pulmonaryhilunr,
rapidly mobillze ihe
lung,gatheringit in your
non-dominaft hand,
and pinchthe bleeding
hllum beiween thumb
and forefinger The
simiadiyto ihe Pringle
maneuverrs oovous.
Now organize youf
anacK: rmprove exp
os!re, "mainslera ' ihe
endotracheal tube i.to the conlralatefalbronchusif possible,and get a full
sei of vasc!lar instfumentsand an autotranstusion device.

At th s point,your oplionsdependprimarilyon the mechanismof nlury.

With a simplestabwound,pinchingthe ifjlred hium maygiveyoLrjLtst
enough control and visibilityto rapidly do a aieral repalr using 5:O
polypropylene. The situationbearsan uncannyresemblance io the injured
portalve n n the hepatoduodenaligament.In boih cases,you are dea ing
with a laceratedlow-pressure(but h gh flow) sysiemwiih n a very narrow
anatornicspaceihat affordsyou litlleroomfor maneuvering or comfortable
clamprng.

Controlthe pulmonaryhilumbetweenthumbandforefinger

A centralglnshot injuryis bad news. Dar.age is r.ore extensive,you

often must clampihe hilur., and may be forced to resecia lobe (or even
the entirelung)io achievehemostasis. A theoreticallyappeallngopton fof
hilar injuriesis vascularcontrolfrom within the pericardiumbecalse it is
basedon the prlncipleof anaiomca barfers (Chapter3).

lf yo! open ihe pericardiumanteriorand pafallelio the phrenicnerue,

you are work ng if uninjuredv rgin terrilory,much ltkeworkingabovethe
inguinallgamenln a groingunshotwound.However, thislakestimeand
 TOPKNIFETheA.t & Crcriiol TroumoSurgery

requiresthorough kfowledge oJ itrtrapericardiai a|atomy - nol a good

opiion for the gerieralifauma surgeor facing a certral lung injury n a
rapidlyexsanguinailng patient.In practice,a gunshotwound closeto the
pulmonaryhiufir meansa rapid lobector.yor, in extremecircurnstances,
pneumonectomy,

A siapled pne!nrofectomyis a technicallysimple blt physlologicaly

devastatrngoperatrvemaneuverrso use it as an absoluie Lastresod,
Exsanguinai ng traunrapatientsdo not iolerateacute removalof the iufg.
Pneumonectomy slops the bleedng but often eads to acuie right heart
failure,henrodyfamiccollapse,and very high mortality.

lf, despiteall efforts,you haveno choicebut 10take out the lung,bring

a 90mm inearsiaplerw th a vascularstapleload acrossthe eni re hilum.
The iechnicalprincple is to movethe siapleras d sial as possble io give
yourseLfroom for a suture llne should siapling requife reinforcement.
Carefuly closeihe stapleracrossthe entirehilum,fire it, and removethe
ung.Takehold of boih edgesof the stapledstumpwiih Allis ciamps,and
oniy then releasethe stapler There s alwaysresidualbleedingfrom the
stapledlineof reseciion.Controlii wiih a runningmonoflamenislture.

Do a stapled pneumonectomyonly as a last reso{

The thoracic esophagus

Approachan injuryto the upper and midthoraccesophagusthrougha

rrghtposierolateral
thoracotomyin the 4ih intercostalspace.The injured
lower thoracic esophagus is accessed ihrough a left posieroaleral
thoracoiomyin the 6-7th ntercostalspace.

The bailout so utionfor an esophageaperforationis proximaldrainage

to convedthe fiee perforatoninio a controlledfistula.The cardina sin is
creatinga dead-efd esophagealpouch above ihe injury,an ufdrained
'pus sausage"
that is a source ol ongoing sepsis and slowly kills the
paUent.
 l2 The Chest: lnsideand Oui

Drainthe perforationby
inserting a large-bore
suclion drain through ihe
perforaiionand up intothe
proximalesophagus,and
secure it in place. lf you
can get an esophageaT,
iube, use it. lf possible,
approxrmate ihe edges of
the holearoundthe dfain-
A ways rememberto drajn
the pleural space with a
separatedrain or a tube
thoracosiomy.Use this
damage conirol option
when you have to bail oui in a hurry,the injury s too largeto be
approximated is delayed(morethan12-
withoutiension,or the operaiion
24 hoursfrom injury)and the pleuraispaceis severely inflamed,
making
primaryclosureunsafe,

An esophagealperfofaiionis a hole ln the gut. lf you decideto close it,

alwaysbeginby carefullydebrjdingand deflnlngthe edgesof the nrucosal
defect,just as you would do for any other part o{ the Gl tract. Do not
mobi|zelhe esophagusout oI its bed becauseyou will devascularzeit,
jeopardizingyour repair.Close the perforationin two layers(mucosaand
muscle), anddrainthe pleuralspace.

Coverihe repairwiiha vascularized pedicleof tissue.Dependingon ihe

operaiivecircumstances,ihis can be an iniefcostalmuscleflap, a Thal
patchof gasiricfundus(Chapter5), or a chunkof omenium.Perlcardialor
pleura flaps are not well-vascularrzedn ihe acute settinq,so don't use
them. Providea roule for earlyenieralfeeding

pe orationas a bailout solution

Drainan esophageal
 TOPXNIFE
]he Ad a Crofi of TroumoSurgery

The majol airways

The ciose anatomicalproximltyof the major airways io the greal

vessels,esophagus,and lungs viduallyguaranieesyou will rarely
encounter an isolated injury to the intrathoracictrachea or a major
bronch!s. [,4ajorairwayinjurytypicallyiakes second seat to hemorrhage
becausegushingbloodtakesprorily over leaklngair.

The damageconirol soluijonfor an rntrathoracictrachealirjury is io

negotiatethe efdoaachealtubepast the injury bypassingjt to preventa
massiveair leak. For a rnainstembronchusinjury,ihe bail olt soluiionis
mainsiemmingihe endotrachealiube into the contralateralbronchus
(Chapterl1). Air Jeaksfrom smallerarrwayscan be managedinitiallywith
a chesttube, with delayedreseclionof the involvedlobe.

lf, during thoracotomyfor trauma, you ercounter a straighfiorward

lacefationof the tracheaor a major bronchls, fix it with a singe row of
interfupiedabsofbablesutures.Do not use a non-absorbable sutufein the
airways;il leadsto granuoma {ormaiionand taterstenosis.Fof all other
iniurjesthai requirecomplexreconstrlctions,the smartestthing you can
do is resistthe temptationio tacklethem or yourown, and get the helpo{
an experienced thoracicsurgeon,

Fixskaightforward
majorairwayiniurieswith absorbablesuture

THE KEY POINTS

Sutureinlercostalbleedersparallelio ihe ribs.

Pulmonarytfactotomyis a neatsolltion to a difficultproblem.

Conirolthepul..onary
hilumbeiweenthumbandforefingef.

) Do a stapledpneumonectomy
oniy as a last resort.

Drainan esophageal
perforation
as a bailout sotLrton.

Fix straightforward
malora rway injurieswith absorbablesuiure.
 Chapter13
'I
horactcV ascular I ra uma
for the Ceneral Surgeon

The rcad to the heart is orrlY 2-3cm in a dircct lifie, but

it has taket surgery flearl! 2400 ye.rrs to haoel it'

- H.M. Sherman

Injlries to ihe heari and ihoraclc great vessels have an idtating

tendencyto force lhemselveson you. ll you ate a g€neralsutgeon'the
majorvascularstructuresof ihe chestare not yournat!ral habitat,and you
wou d much raiher havea cardiothoraciccolleaguedeal with ihem With
bluni aodic injuriesihis is noi only Posslblebut ls also a good ldea
becauseyou are dealingwith a containedhematomaThere is time to
delineateihe njury by angiography,consldervariousoptions (including
endovasculafrepair),or transferthe Paiientto anotherfacility Not so with
penevatingitauma, where the patieni is activelybleedingand often ln
shock. You musi take a deep breath _ and plungein A phone call to a
cardiac surgeon is noi a valid resusciiativemaneuverfor cardiac

This chapier deals with lhoraclc cardiovasculartrauma from the

perspectiveof the generalsurgeon Most penetratlnginjuriesio the heart
and thoracic great vesselscan be fixed using straightforwardvascular
principlesand techniques.lf you gain rapidaccessto the injuryand keep
yourwlts aboutyo!, yoLlhavea good chanceof savingthe patent

Accessingthe bleeding heart

The operativeencounterwith a stabbedheari is often one ol the "osi

rewardng experencesa surgicalresidentcan have li involvesa rapld
simple procedurethat revivesa patlentwho, uniil a {ew minutesear ier,
 TOPKNIfElhe Arl & Croit of lroumo SLJrgery

was virtuallydead. Don'i let ths gfatifying experiencemislead you.

Cardiacinlufrescan alsobe extremelyviciousand leihal.Theyconrein iwo
flavors:simpleand complex.

A simplecardac injuryis a smallaccessiblelaceration,rnosl often a

stab wound. Oulcomeis deiermned by how quicklyyou crack ihe chesi
and releasethe tamponade.These patientsdon'i die ol exsanguination,
and cardracrepairis usuallyeasy.

Complexinjuriesare mutiple, inaccessrble, large, or involvethe

coronaryarteries.Reease of tamponadeis onlythe firsi step in an uphil
battle.Conrplexcardiacwoundsare Blc TROUBLE(Chapter2), carryifg
very high morlaliy ratesevenrn the most experencedhands.

How do you get io the woundedheart?lJyo! haveakeadybegunwith

a resuscilativelhoracotomy,open the pericardum longitudinally, anteror
to ihe phrenicnerve.Releasethe tamponadeand deliverthe heart nto ihe
operativefie d. Injuriesio ihe righi side of the rightventricleor to the right
atrum cannoi be reachedthrough a left anterolateralthoracotomy,so
extendyourrncisonacrossthe sternum.

lf the patieniis not ,inexfremls,considerdo ng a mediansternotomy.

This incisiontakes a ittle more time, and your access to a postenor
cardracwoundfromthe front is moredifficult.We prefera leftanterolateral
ihoracotomyfor most cardiac wo!nds, especiallygunshot inj!ries that
often involvedamageto oiher ihoracic structures.We reseruemedian
siefnotomyfor precordialstab woundsin relativey stablepatients.

Do a leftanterolatefal for cardiacgunshotwounds

thoracotomy

4 A,MI @-4 ".z"zc1 tW*V.-r"*

to l
F 5f--',t ?+
 l3 ThorocicVascuorTrauma for ihe GenerolSurgeon

Temporary bleeding control '

Oncernsidethe pericardium, rapidlyevacuatebloodand clots,locate

theinjury,andselectanappropriate lemporaryhemostatrctechnique.Youl
assistant'sfingeris an excellenl
firstchoice,butthereareotheroptions.

During resuscjtativeihoracotomy in ihe shock room, temporarily

staplingthe lacerationwiih a skin stapler s a cooltrick since a stapleris
so much saferihan a needle.Conirola largerwound by insertinga Foley
catheterthroughthe holeand inflatingil. Use a Satinskyside-biiingclamp
to conlrola rohl atrialLaceration,

lf the damageis extensiveor the

injuryinaccessible,you may haveto
resortto temporaryinflowocclusion.
lf you clamp both the superiorand
inferiorvenae cavae, ihe heart will
emptyand siop, givingyou a couple
of minutes(not morel) to suturethe
lacerationin a dry field. ll you are not
a cardiacsurgeon,the simplestway
io achieve inflow occlusion is by
co..press ng lne \lg!]._jl]Illl!!-r
manuallyagainsttheheartin a lateral-
to-nredial direciion so the atrium
 ToP KNTFE
TheArt & Croft of TraumoSurgery

cannotfill.Useinflowocclusiofonlyif youhavenootherchojce.lt is easy

to siopthe heart,butmuchmoredifficultto get it goingagain.In a cold,
fibfillating
heart,inflowocclusion
willbe a termnarevenr.

Inflow occlusion is your ultiftate weapon in cardiac trauma

Restarting the heart '

When the heart s not contractingeffectivey, begin open cardiac

compressions.lf operatingthrougha mediansternolomy,compressihe
heart between bolh palms (wlihout thumbs). In a left anterolateral
thoracotomyyour wofk space ts imited, so compress with one hand
againstthe sternum.Restarttheheartus ng a combinationof opencardiac
massage,cross-clampingof the descendingthoracicaorta, eplnephrine
(1mg) io achievecoarse ventricularfibrillation,and cardioversionusing
iniernalpaddlesappliedd rectlyto the heartai 1O-30Joutes.

What shouldbe yourfirsi priorityif ihe bleedingheariis not coniractifg

effeclively?Shouldyou fx the lacerationfirst? Rapldlycosing a cardiac
lacerationbeforeit resumesdancng rn front of you is certainlytempiing,
but it maytakeiinie,and your repaifnrayfa I apartwhenyou compressthe
heart and iniect lnotropes.Epifephnneis the eremy of the myocardial
suturelinebecauseit inducesforceJulconiraciionscausng suturesto rip
throlgh the musce. lf you fix the acerationand then restartthe heart,you
may haveto reinforce(or evenredo)yoursuturelineonceihe heartbegins
beatingagain.

Resiariirgihe heartafter repairmay not be easy.A severelyacidotic

palient wll benefitfrom a bous of sodium bicarbonatepfior to
deflbrillation.
Evennrore mportantis externalirigationwith warm salineto
rewarmihe head irnmediaiely beforeapplyjngihe paddles.Use lnotropes
only if nothingelse works.

Epinephrine
is the enemyof the myocardial
sutureline
 l3 ThorocjcVosculorTroumofor ihe cenerol Surgeon

Repairingsimplecardiacwounds

C ose a simple laceration

with a 4r0 qg&absorbable
monofilam6ntsuture.Sew n9
the contracUngmyocardium
is more difficult than
optimisiiclluslraiionsiike this
lead you to believe.Noi only
are you workng on a movrng
targei, you aso are dealing
with a musclethat tearsquite
easly,

Some surgeonsuse Teflonpledgetsto reinJorcethe sulure ine. We

repar a laceratedveniricleaviihinterruptedsimplesutures.Yourbites inio
the heartmuscleshouldbe deep but not full-thickness. The diffcult part is
not placingthe suiures,but tying them. Unlessyou take specialcare not
to tighienthe knolstoo much,you will end !p with a torf myocardiumand
a bigger holero fix.

ln an elderly patient or an edemaiousor friable myocardium,use

horizontalmattresssutures wiih pledgets. Partial inflow occlusronby
manuallycompressingthe rightak um lowerspressuresin the v€ntricles,
a usefuladjunctwhen sewinga compfomisedmyocardium.

Since pressurein ihe righi atriumls low, you often can controlan atrial
lacerationtemporarly with a partiallyoccludingSatinsky-type clamp and
then fix it with a runningsuture,as you wouLda arge vein. Grazingnon-
penetraiingrnyocafdialwounds oftenb eed persistentlyand requiresuture
repaifjust ike a lull-ihicknessaceraiion.

Tyingsutures is the challengewhen sewing head wounds

E ,o, a",rr rnuon & croJroi Troumo
suraerv

Complexcatdiacwounds

When.youcan,tfix the injufedheartwiih a few

. simplesijtches,you are
:"d rasa nigh,ihetihood
yoJroarieni or 1orna(.ng
f T-n-".
rr, une $uch "1n".,.
?.,^1
eramplFis a posterio. card,acwound.to get,o a postertoi
hole,you musi Jiftihe heartout of its bed, but the heart
often protestsby
devetoorrgventncLla.arrhylhmiaor arresring.In fact,trl ng
lre reert up ,s
anorherway oi achievirgin|ow occtusion, Be awareof th,s wnen yoJ
manrpulatethe heart,and lift ii gentiyand intermillently
whenaddressinga
poslerlorhote,

The technicalsolution
for a /aceraiioncioseto a
coronaryartefy is a deep
horizontalmattresssuture
that dives beneaththe
aftery.Take special cafe
when tying this suiure
because S-T segment
changesor new O waves
on the ECG monitormay
force you to removethe
strtch and fedo it. An
Inlury to the coronary
artery itself is iypicaly
distal sinc_"paiientswith
transectionof a proximal
coronaryvesselare usually
dead on arrival. Your
realisitc option for a
cardiaclacerationwith a iransecteddistalcoronaryarteryis to ligatethe
vessel and repair the hole, accepting ihe inevitabteischemi; of
the
correspondrng ',,,
myocardialseoment.
ir r+ *,:*! . '*-",rJ ^{\-i1
" L.^4
Cardiac tamponadecaused by lnjury to the intrapericardial
oreat
vesse'sis usJallyreha,.
On rhera.eoccdsiollratyor,pnco.:rre, i. ir I hve
patient, success hinges on your ability to fapidly identify
the inlury,
 l3 Thorocicvoscuar Troumofor lhe GenerolSurgeon

temporadlyconlrol il wiih your Jingeror a Saiinskyclamp' and fix ii with

simplelatefalrepair'mucheasiersaidthandone

In traurnaatlasesand iexlbooksyou ofien see descriptionsof heroic

repair techniqueslor an injuredcoronaryartery,patch repair of a large
myocardialdefeci,or complexreconstructions great
ol the inirapericardial
vesseLs. Althese may be possiblein specialcircumstances when a
cardiolhoracicsurgeonand a pump team happen io be readilyavailable
However.for ihe routinetraumapaiientarrivingin the middleof the night
with a penetratingcardiaclnjuryand operaiedon by ihe traurnasurgeon
on calL,lhey are scienceficlion.

Usequickand simplesolutionsfor complexcardiacinjuries

The tholacic outlet

How to exvlorea meiliasfi al her atoma

Mediansternotomyprovdes
excellentaccesslo the superior
mediastinum. A mediastinal
hematomalooks Like a large
chunk of red jelly sittingabove
ihe pericardium,oozing blood
and obscuring the anaiomy.
This red jelly usuallysignifiesa
major vascular injurY in ihe
ihoracic oulei that You mlst
find andfix.

Exploring ihe suPeiormedia_

slinum is remarkably simllarto
expLoring ihe neck,as described
in the nert chapter.Both are essentiallya lrip ihrougha minefieldunder
sniper flre. You must follow a trail of safely from one key anaiomlcaL
landmarkto ihe nextto guaranieea safedissectionand siayoui oftrouble
 TOPKNIfETheAri & Croft of TroumoSurgery

Once insde ihe chest,identify

the upper border of ihe
pericardum. lf the ihymus is in
your way, divide it between
clamps and ligaie lt. You are
looking for the ielt innominate
vein. lt is the gatekeeperof the
mediastinum,just as the facial
vein is n the neck.Divdingand
ligaiingthe lefi ifnornnate vein
opens!p thesupe ormediasiinlm
and gives you access 10 ihe
supeior aspeciof the aorticarch
andrtsbranches.

Disseciionn a mediastinal
hematomais nevereasy.lf
you fee ost, a usefullrick
is to open the pericardium
to orient youfself. The
pedcardum is an anaiomical
barrier that blocks lhe
extensionof lhe mediastinal
hematoma,jusi like ihe
inguinaligament blocksthe
extensionof a groin hem-
atoma (Chapier 3). By
opening the per cardium,
you can follow ihe aortc
arch upward into ihe
hemaloma to identify ihe
vessels oJ ihe ihoracc
outlet.
 I 3 Thoroclcvoscuor Troumo for ihe GeneroSurgeon

After ideniiiying and

dividing the left lnnominale
vein, your next stop on the
mediastinaltrail of safeiy is
the bifurcation of ihe
innominaleariery,the media_
stinal equivaleni ot the
carotid bifurcationIn the
neck. Your kay landmarkis
the right vagus nerve as lt
crosses in front of the
proximal right subclavan
artery.Fallureio identi{Ylhe
vagus in ihe mediastinum
-
has ihe same consequencesas il does ln the neck an inviiaiionfor
iatrogeniciniury

hematoma
Followa trail ot safetyin exploringan uppermediastinal

Youf nexi priorityis proximaland distalcontrolof the bleedingvessel

The vesselsof ihe superiotmediastinum are niceLyarrangedin two layers:
s!perficialveinsand deep arteries Again' the simllarities to the neck are
Control
strlklng. a venous injurywith a side-biting clamp,and fix ihe hole
lf a simple lateral repair will noi do _ ligaie the veln without a second
thoughi.

When disseciingthe proximalleft carotidartery,you musi ideniifyand

preservelhe left vagusnerveas it descendsbetweenthe caroiid and Left
subclavianartedesto cross in front of lhe aorticarch and give o{f the left
recurrentlaryngealnerve ProximalcontroJof the lefi subclavianarteryLs
discussedlaier in thrschapter

Neverjust plungeinio a mediastinalhemaiomafrom blunttrauma The

most common blunt arterial injury in the upper mediastinumrs an
(widened
lnnominaiearteryinjurythat presentsas a coniainedher'atoma
superior mediastlnum)in a hemodynamcallystable patient Bllndly
enteringlhe hemalomais the worst possibleerror you can make lhe
inlurvjs avulsionof lhe lake_offof the innominatearteryJromlhe aortic
aich. In other words, you are dealingwith a sde_holein the aorta lt
 TOPKNIFE
TheArt & Craft of TroumqSurgery

doesn'ltakemuchsurgicalimagination io realizewhatwil/hapoenif vou

oelvento -hrsrFnatoncu'rprepa.eo. lne correclapproac-is or;Jlv
ouilinedin the nextsectionof thischapter

How about distal

control of thoracic outlet
injuries?As a generalrule,
the exposureprovidedby
a median sternotomyis
oltennotsufficentto a ow
dista conifolofthe carotid
and subclavian vessels.A
medran sternoior.y is,
however, an eminenily
extensleincision,so yor,l
can easilycafiy it Intothe
neckor alongthe clavicle.
lf you are going into the
reck, drvide the strap
muscresoown |ow, fear
the r inseriion inio the
sternum, to expose the
carotidsheath.

Neverplungeblindlyintothe mediastinum
in blunttrauma

Definitive repair and damagecontrol options

In the upper mediastinumyou almosi never dea/ wiih an isolated

penetratinginjuryto a singlevesse. Thereare alwaysassociatedinlures,
and clampingthe rnnominate or caroiid arterycarrlesa subsianialrisk o{
stroke.So don't fiddle w th ihoracicoutlei iniures; use the simplestafd
quickestsolutionthat will give an accepiableresult.In most cases, this
meansa syntheticrnterposjtion grafi.We preferknittedDacronratherthaf
ePTFE becauseil is a softer graft with less needle-holebteeding.The
 'geon
1 3i ' o o . ' , o ,uo' I ou-o o I 'Ge__'ol5

normalarteriesof the thoracic oullet afe extremelyfriable,and sewrng

ihem often feels ike sewingwet lissue paper

There are ony linriieddamagecontrol options in the thoracic ouilei

Ligaiionof the injuredarteryis certainlyan optionif you accepi ihe risk of
slroke. A temporaryintraluminaL shuni is iheoreiicallyaPpealingand has
been usedtwice by one of oLlrcolleaguesbut with no ong_lermsurvivors
'bypass
The onlyspeclalvasculartechniquein the thofacicoutlelis the
and exclusion repair of blunl innominaleariery lnlury ll you arent a
cardiothoraclcsurgeon,you are unlikelyto find yourselfoperatingon this
injury,since the paiientsare hemodynamlcally siable with a coniarned
hemaioma.You should, however, be familiarwiih the techncal principle

The bypass and exclusionrepair begins by exposingthe ascendlng

aortainsidethe pericardiunrand then obtalnng disla!contro on ihe distal
innominate,right subclavianand right carotid arteries The s!rgeon
deliberalelyavoidsenteing the hemaiomaaroundthe ptoxlrnalinnomlnaie
artery.A pariialy occludng Saiinskyclampplacedon ihe ascendingaoria
allowsihe surgeorto sew a 12nrmknittedDacrongraftend{o side io this
sde-clamped aortc segrient The innominate adetyls thendlvid€djust
proximalto its bifurcation,and the distal anastomosis(io ihe disia
innominate) is completedOnlyihenisasecondpartially occ udingcamp
placed on the aorta around lhe take_off of the lnnominate artery The
hemaiomais entered,and the side hole in ihe excludedsegmeni of aorlic
arch is closedwith pledgeiedsutures

[JseDscronfof thoracicoutletarterialreconstructions

The azygosvein

In penetratingchest traunra,azygosverninjuryis seenin conlunctron

wth lnjures to the adjacentcentralalrways,esophagus,or thoracLcout et
vessels.The chalengewith an azygosvein injuryls geltingio lt. Access
througha mediansternolomyis extremelyditficult,and it may even be
 TOPKNIFETheAri & Croft ol TroumoSurgery

difficultio reach lhrough a righi anterolateralthoracotomy,requiringan

extensionacrossthe sternum.The irjury is tolgh 10identifybecausewhat
you Lrsualysee s just a hole in ihe right posteriormediastinumhosing
venousblood. Onc6 identified,clamp and suiure-ligaiethe injufedveln,
and meiiculouslysearchfor associatedjnjufes io the adjacefi bronchus
or esophagus,

The subclavian vessels

Before you embark on an adventurearound ihe sLlbcavianvessels,

palse to assesshow necessaryit reallyis. Are you operatjngfor bleeding
or ischemia?lf your circumslancesare unJavorabie (i.e. austere
environment,lack of experience,other grave injuries),you nraywell be
ab e to posiponethe operation.If bleedingis from a missiietract, inseria
Foley nto it and inflaielhe balloon(Chapter2). lf this stopsthe bleeding,
an lmnrediateopefatlonmay not be necessary.lf ihe arm is ischenric,a
simpleforearmfascioiomycan buyyou valuabletime. Endovascular stents
or stent-graftsare effectiveali€rnativesto surgicalrepair of subclavan
injuri6sin non-bleeding patients.

lf you decide to proceed with an operation,proper positioningand

drapingare crucial.Placea shouldefrollverticallyalongthe thoracicsprne
to drop the shoulders back. Suppod the head and roiate it to the
contralateraside to extendihe neck. Prep and drape the patrenl'schesi
with the upperexiremiiypreppedfree so it can initlallybe fullyadduciedat
the patent's side and later abductedas necessary.You can get to the
subclavianvesselsthrougheithera supraclavicular incisionor ihe bed of
the clavicle.Your choce of incision depends on the opefaiive
circumstancesand your experience.

lfyou are not surewhefethe njuryis locatedalongthe subclavan artery

or if you don't haveexperiencewith subclavianexposure,the safestway
to obtainproxjmalcontrolisthroLghthe chesl.Use a high (3rd irierspace)
eft anterolaiefal
thoracoiomyincisionfor injuryto the leftsubclavianartery,
or nrediansternoiomyif the injuryis on the righi.
 I3 Thorocicvascuorrro!mo for the Genero E
"'ntt"

When exploringa non-bleeding

subcJavian injurywith mrnimalorno
hematomaaroundthe clavicle,we
prcfer a supraclavicular incision
lvlakeyour incisiona lingefbrcath
aboveand parallelto the clavicle,
extendingfrom the sternal notch
lalerallyto the distal third oi ihe
bone, a distanceof approximaiely
8-1ocm. Dividethe Platysmaand
place a self-retainingtetractorin
the wound, You must now go
throughtwo layersof muscle.

Th€ first layer conssis

of the claviculafhead of
the sternocleidomastord
andthe omohyoidlaierally.
Cut bothmusclesas close
to the clavicleas Possible,
then reposition Your
retractorin a deeperPlane
to op6nthe wound.lf You
see the internal juguLar
vein, deiine its latetal
border and reiract it
medially oul o{ harmsway
Now you can accessand
isolaiethe subclavian veln,
bul the arteryis hidingone
layerdeeperdown,behind
ihe anierior scalene

Behindthedividedslernocleidomastoid, ihescalene
idenlify fat padand
caretully it fromlateraliomedjalln
mobilize searchofthe phrenic nerveOn
lhe leftside,youshouldbeableto identitihethoracic ductas ii entersthe
and iniernal jugularveinslf iniured'suture'
iunclionof the leftsubclavian
ligateit witha 6:0polypropylene il
suture; not' eaveI abne
 TOPKNIfETheAri & Croft of TroumoSurgery

The key analomical

iandmark n exposingthe
subclavian artery is the
phrenicnervebehindlhe fat
pad. During a subclavian
exposure,it is the ort
slructureyoumustpreserve
at any cost, even f the
anatomy is hostile. lt
crossestheanteriorscalene
musclefrom up and lateral
1odownand medial.lsolate
the nerveon a vesselloop
and gentlyreiract it out of
yourway,Now cui the anteriorscalenemlscle as low down as you can,
We dlvidethe musclepiecemealwiihscrssorsand noi diathermybecause
it does not bleedand is closeto the brachia plexus.

L"J'A Only a lhin periartera

f, -\ 4-'Y lascia rernainsbetween
you and the subclavan
adery Inciseit to identrfy
the periadveniitialplane
of safeiyand encirce the
artery.The thyrocerucal
trunk s com ng straightat
youandls typicallyin your
way.Dividingand ligating
t helpsyou nrobilizeihe
subclavianartery.Clearly
identifythe vertebraland
Intemalmammary arteaes
comirg offthe firsi partof
ihe vessel to prevent
accidentalrnjury.

Thephrenicnerveis yourkeyto the g.tbclavian

a*ery
 ! 3 - h o r o - ' .v o . ! o, 'ro 1o o _eCan'o 5 roeo'

As always,things become considerablylivelierwhen lhe subclavian

fossa'
adery is bleeding An expandinghemaiomafiLlsthe clavicular
makingit difiicultto evenpalpatethe clavicle When operatlngundersuch
adversecircumsiances,we preferto go throlgh the bed of ihe clavlce
becausei s a quiukera1dsimpleftoLle
'/h.t",'\ 4rd'1 +^ PL- 'lA
Make your incisiondLrectlyon the clavlcleio exposethe medialhvo_
thirdsofthe bone.Scorea lineon the anteriorsurlaceofihe bonewiih ihe
dialhermy.Now use a periostealelevatorlo peeLihe periosteumotf the
claviclein a circum{erential fashion Dividelhe clavicleas far laterallyas
you can wiih bone cuiters or a saw, then graspihe medialffagmentwith
a towel cLip,and yank ii oul of iis bed Usingihe diathermy,takethe head
of ihe clavicleoff the siernum.Cuttingthe subcaviusmuscleimmediately
deep to the clavice bf ngs you face-toJacewiih the pfe_scalene lat pad
and the phrenicnerve,and you know your way io ihe arteryfrom ihere

DistalcontroLol the subclavianarterymayrequireclampingthe proximal

axillaryartery.lf the clavicleis intact,clamp ihe axillafyarterythrougha
sgpil3lCjlll3gbllg.Ulqrincision Howevet it you temovedihe clavicle,you
hive an extensile inclsion ihat can be cary'€d laterallytoward ihe
aeltop"ctoil$ooi66 artifi=_
theaxillarv
""pise
The damageconttoloptons for an injLlredsubcavan arieryafe llgation
or lemporary Boihwofk Ligauonis usually
shunting. welltoeraiedif the
pathways
iniuryhasnot destroyedthe majorco!lateral around the shoulder
Addinga pre-emptive forearmfasciotomyis a prudenimove'

lf you know your way aroundihe niuredsubclavianariery and don'i

have10bailout, repaifit Unlessdealingwith a aceraiionthat can be fixed
wilh simple laietal repaif, we again advlse you go directy lor an
intemositiongraft.Mobilizingthe sott and friablesubclavianarietyto gain
enoughlengthfor an end-to-endrepalra mostneverworks We isolaieihe
injuredsegmeniand clamp ii, definelhe lnjury,do a proximaland distal
F;gady thrombectomy, and lnsertan 8mm Dacroninterposition graft We
do noi replace the clavicleafter completing the vasculafreconstructlonr
bul coverthe tepairwith healthymuscleand soft lissue

Go throughthe bed of the clavicleif the patientis bleeding

 TOPKNIFE
TheArl & Croft of TroumoSurgery

The descendingtholacic ao*a

The patientwlth bluntlnjuryto the descendingthoracicaortais typicaty

hemodynamlcally stableand hasa coniainedmediasiinalhemator.a.Don,t
iorget that if the paiieri s unsiable,ihe sourceof hemoffhageis alnrosi
nvariably in another analomical compartment, iypically below ihe
oraprragrn,

Again,if you are not a cardiothoracic

surgeon,you are not likelyio find
yourselfin the left chest,face.toJacewiih a bluni aortc injury.Howevef,
be famlliarwith ihe generaltechnrcalprinciplesof the repair.Endovascular
t.eatmentoffefsan effectivealternaiive
to operaiiverepairofthese injuries.
Althoughstil under evaluation,this nrodaltymay becomethe preferred
approachwithinthe nextfew years.

The classicbluntaodic injury,locaiedimmediatelydistalio the take-off

of ihe left subclavianartery, is repairedthrough a left posierolaieral
ihoracoiomyin the 4th ntercostalspacewih singlelung ventilation.The
major palhophysiological chailengeis central hypertensroncaused by
proxmalaorticclamping.Pharmacological agents,a passiveshunt,or
pump-assisled atriofemoralbypass,typicaly usinga centrifugalpump and
no hepann,areyouroptrons.

The technicaldifficultyin ihis operationsiemsfrom the close proximity

of ihe aortictearto the originof ihe subclavianadery.The pleuraoverying
the proxima eft subclavianartery s opened,and ihe adery s encirciedby
bluntdisseciion. Usinga combinaton of sharpand bl!nt disseciion, ihe
surgeo. then encirclesthe aorta between the left subcavian and efi
caroiidarteries,creatingjuslenoughspaceto accommodate a clar.p. The
key maneuveris developinga plane betweenthe lndersurface of the
aortic arch and ihe pulmonaryartery. Dista control is obiained by
encirclingihe drstalthoracicaortaabovethe diaphfagm.

After clamping,the hematomas entered and a careful longiiudnal

aortotomyallowsthe surgeonio assessthe extentofthe njuryand decide
beiweenprimaryrepair (feasibl€in roughly 15% of cases) and Dacron
graft inlerposition.
I torri'e ceneror'surseon
vosculorTroumo
13Thorocic $

) Do a leftanterolateral for cardiacgunsholwounds

thoracotomy

) Inflowocclusion weaponin cardiactrauma

is yourultimato

> Epinephrine sutureline

is the enemyof the myocardial
I sewingheart.wounds'
) Tyingsuturesis thechallengowhen

> for complexcardiacinjuri€s.

Usequickandqimplegolulions

> anuPperm€diastinal
Followa trailofsaf€tyin exploring hematoml'
- '
) Nover plunge into
blindiy the in
msdiastinum trauma
blunt

tharacicoutletarterialteconstrucJionsi
) . Usq D4gr-arriQr

) artery
Thephrenicnerveis yourk€yto th€subclavian

) Go throughthe bBdof the clavicloif th; patientis bie€diirg'

IOP KNIfETheAri & Croft of TroumoSurgery
 Chapter14
in TigerCountrY
The Neck:SaJari

Go to the heartof dange4fot thercyou will find safetq,

- Old Chineseproverb

'tiger country,"a group of viial

The woundedneck is the anatomical
midlinestruciurestighty packedtogether,carryinga large neurovascular
bundleon each side. This delcate anatomyis jusl sitiing insidea lafge
hematomawaitingfor you to make a wrong move Evensurgeonswith
eleciiveexperiencein the neck w ll be chaLlenged by a rapidy expanding
cervicalhematomaihat obscureskey landmafksand dlstortsthe anatomy.
To avoid geiting lost in ihe injuredneck, use the trail of safety,a well
defined sequence of steps thai carefully guides you from one key
anaiomicallandmarkio the nexl withoutgettinglosl of causingiatrogenic
damage.

TRAILOF SAFEW

W1W'7@= Jugulafvein

Followa trailof safetyin neckexploration

 TOPKNIfETheAd & Croit oi TroumoSurgery

Before you begin

Always positionthe paiient yourself.lmproperposilioningcan turn a

straightforwardneck explorationinio the safar from hell. Support lhe
shouders on a shollder roll, and use a head supportto exlendand fully
rotaiethe headto the otherside.The superiormedasiinumis an extension
ol the neck (Chapier13), so youroperatlvefield extendsfromthe mastod
processio the upper abdomenand includesboth neck and chest. Never
begin a neck explofaiionwithout a fulLset of vascular nstrlments,and
rememberio preparea sitefor posslblevein harvestingfrom the leg

Making the incision

The ut ty incisionfor neckexploratLon

runs aong the anteriorborder of the
sternoceidomastoid muscle(SCM).You
can ei(elrd lt from the masioidprocess
io ihe sternalnotch,but a morc limited
inclsionis usuallygood enough.lf you
mustgo a ihe way io the sternalnotch, I
you maybe dea ng with a thoraclcouilet
lnjury where proximalconirol must be
gainedn the chest.As youapproachihe
angle of the mandibe, curve your
incisionposieriorlyto avoidihe margna
nrandibular branchof the facal neNe.

The first layer you encounter

(-, beneaihthe skin is ihe platysma.As
the edgesof the nclson
it is divided,
open, and you are ooking for the
(
anieriorborderof the SC[,4,yourfirst
landmarkon the trail of safety.This
may not be easy in an injuredneck
with an expandlnghematoma.
 l4lhe Neck: Sofariin TigerCounTry

The most commonpilfallis nraklngyour incisionioo posteriorlf, upon

divldlngthe plaiysma,you bumpinio longitudinal musclefibers' moveyour
disseciionanteriorly Gaining ihe anterlor border of the SC['4 is more
incisiol Asyou€ppy
irnponarltral ga n ng tre midhle 4 alaparolomy
o"fiU"rut" uu"oo. *nif" voLrass'sIantapprrescoLrnten'actro'lthe incision
almostopens ilself.

Gainthe anteriorborderof the sternocleidomastoid

Develop youl work space

Freethe anteriorborderoJihe SCIMby pullingit towardyo! and Inserl

a self-reiaining retractorbeLowihe muscleto keep the wound open Th s
ls lhe firsi step in developng your work space

You are now dissecting ir

ihe nriddlecervicalfascia, the
Layerof areolartissue beneath
the retfactedSCM. Yout aim is
io ideniify the inietnal iugular
vein (lJ),your nextlandmatkon
the trail of safeiy.

The lJ is the mostcommonlY

injured vascularstructurein
ihe neck. TemporarilY control
bleeding from this vessel wiih
yourfingeror a smallside-brting
vascular clamP, and rePair it
Lrsing a 5:0 PolYPfopylene
suture.Dont hesitaieto lgate
ihe vein lf repair is not
slraightfoMard.lf the U is not
injured, siay focused on fis
anteriorborder,which leadsto
the nexl landmarkon the trall of
safety- ihe faclalve n
 TOPKNIFE
TheArt & Crofi of TroumoSurgery

The facial vein is the

gatekeeperof the neck, the
key landmark you must
identify,clamp, and ligateto
open the way 10 the carotid
bifurcation. Ligating and
dividingit also allowsyou to
continue developingyour
work space by repositioning
the self-retainingretractorin
a deeper layer so it pushes
the U out of your way. Yoll
are now drrecllyon top of ihe
carotid artery. In most
paients the facialveinis also
a convenientmarkerfor the
levelofthe carotidbifurcation.

In the presenceof a large hematoma,taking the necessarytime to

dissectout the facialvein s a smartmove,evenif you are in a hurry.Keep
in mindthai somepalienishave2-3 smallveinsinsteadof one largefacial
vein,and all must be identifiedand dividedalongthe anteriorbofderof the
U. A classicpitfallis mistakingthe lJ {or the facia veinand lgat ng it, only
to makethe drsseciionmoredifficult.YouhavenegolialedIhe trailof safety
throughthe injlred neck. li's t me to beginthe nexi part of yolr operatoni I
idenlifyingand fixingthe lnluries.
i

The facial vein is the gatekeeperof the neck

The injured carotid

Gaifiirrgcotlttol

Thecardinalprlncipleof obtainingproximal contfolbeforeenieinga

hemaloma appliesto carotidarieryinjuryandmeansisolating
thevesselin
virginterritorypfoximalto the hematoma. Youmayoccasjonallyhaveto
 TlgerCountry
l4 TheNeck:Soforiin

ertend your incisionto the

sternalnotchor evenrntoa
nredian sternotomy to
obtain safe proximal
control. Once inside the
cafotidsheath,find,identiiy,
and protect the vagus
nerve.Encirclethe common
carotid ariery with a
Rurnmel tourntquei and
proceed with dissection
towardthe areaof injury

How about dislal

control? This is otten
problemaiic because a
cervicalhematomatypically
exiendsup io the angleof
the mandible(Chapier3). Therefore,gaining dlstal control outside the
hemalomamay not be possible lnstead,prepareto gain distal conttol
from wlthlnthe hematoma.lf you are readyfor ii, you can controlback
bleedingfromthe iniernalandexiernalcaroiidarterieswith minimallossof

As wiih any other namedartery in the body the safe planealong the
carotidthat protectsyoufrom mischiefis the periadventitialplane(Chapter
3). As you reachthe injury,you encounterback bleedingfrom lhe internal
and exiernalcarotidarterles.First, use your fingef for temporaryconirol
Then, eiiher clamp the distal artery or insert an intralunrinalFogarty
catheterconneciedto a 3-waystopcockintothe outflowtfact. Remember
that the hypoglossalnervecfossesoverihe proximalinternalcaroiid,and
the vagus nerve lies just behindit You have come to the heari ol tiger
plale and bluntlypush asrde
country,so stay in ihe sa{e periadventilial
(rather than cut) any unideniifiedstruciures Definitivecontrol of ihe
carotid bifurcationmeans occluding all thtee vessels: the comrnon'
internal,and exlernalcarotidarteries
 TOPKNIFE
Ihe Art & Crofi of TroumoSurgery

Once you havecontrolof the lnluredcarotid,lalk to the anesthesiology

teamlo assurethe patienthas a good blood pressure(a meanof ai least
100mmHg)while the carotid is clamped.This is even more critical if
backflow
fromtheinternal
carotid
is notverybrisk.

Stayin the periadventitial

planeof the carotid

Carotid f ep&its siflxplified

The carotidarteryolayoung healihyaduli s surprisinglysoft and pliable

and doesn'l toleraieabuse. Unlessyou are very gentle,you will end up
wiih a lorn arteryor a repairihat looks like a dog's breakfastand has to

There are many cool trcks for repairingthe carotid artery,incuding

such soohisticatedmaneuversas transDosiiionof the mobilizedexternal
carotidto connectit to the disialinternalcarotid.We adviseyou lo keep ii
verysimpe andforgetthecoo siuff-oryourpatient wilpay the pricewith
a stroke.use ihe simplestand fastestmeansto revascularlze the bra n.

Are ihere damageconirol optionsfor a carotid injury?DefinilelylWe

have no personalexperencewilh temporaryshuntsin the carotid,bui rt
makes perfeci sense. lf the patieni s about to breachlhe physiological
envelopeor thereare olher mofe life-threatening injuries,ligationis a valid
oplion.When consideringigaiion,rememberlhe d tierencebetweenihe
common and inlefnalcarotid arteries.Ligatingihe former is often well
toleratedbecausethe internacarotidremainsperfusedby backflowtrom
the exierna cafoiid. Ligaiing lhe internal carotid, especially in a
hypotensve palient,caffiesa significantrisk of stroke.Youmay decde lo
lake that risk to savethe patienis life.Ligations your only realisticoption
for inaccessiblernternalcarotidinjuriesin Zone lll. Some surgeonsligate
ihe internalcarotldarieryif lhe patent has a profoundneuroLogical delicit
(coma),whileoihersreconslructil regafdlessof the patient'sneurological
sialus.The prognosisrs goingto be very poor rn efher case.
 l 4 T h eN e c k : 5 o f o r l i nT g e rC o u n i r Y

What are the definitiverepair opiions? On Tareoccaslonsia clean

laceration(usuallya stab wound)may be amenabl€to simplelateralrepair
or end{o'end anastomosis.In most cases we use a syntheticgraft or
Datch1or€constructthecarotid.We rarelyuseveinbecauseit takesmore
iime to harvesiand prepare,andthereis no good evldencethatthis makes
the slighiestdifference.

in ihe lniured
Beginby exploringthe injury.Openthe arlerylongitudinalLy
areato definethefullexlentofihe damage Caretully debridethe coniused
or iniuredsegmentto oblainheallhyaderialwall wiih a normalintlnraon all
sldesof the arterialdefect.As you definethe injury planahead

Preciselydefinethe carotidiniury

Your nexl step is thrombectomyto clear ihe inflowand outflowtracts

Carefullypass a No. 3 Fogartyballooncatheterproximallyand distally.
Don't push the caiheterdlstallymore than 2-3cm pasi the bi{urcation-
diving ii throughihe carotidsiphonwill havespectacularresults Flushthe
proximaland distalends of the injuredarterywilh heparlnizedsalineand
begin the repair. lf inseriing an interposiiion graft, do the disial
anaslomosisfirsi, especiallyif you are hookingup io the iniernalcarolid
abovethe bifurcation.lt is difficultiowork on the posteriorwallofihe distal
anastomosiswhenthe proximalanastomosisis akeadysewn in

Whal should you do if there is no backflowfrom the dislal Internal

carotidariery?This is a conitoversialpoini.We preferto hgatethe artery,
lor fear of convertngan ischemicstroke into a hemorthagicone Some
surgeonsfeconstructthe arteryregardlessof backflow

lf you haveexperiencewith electivecarotidsurgeryand know how to

smooihlyinserta shunl and work afound it - considerdo ng just lhal A
shunt is a smart move,especiallyif backflowfrom lhe iniernalcarotidis
weak or reconstructionis going io take iime Thteadyour shuntthrough
graftbeforeinsedion,and do the€niiredistal
the lumenofthe lnterposition
and mosi of the proxlmalanastomosis with the shuntin place
 TOPKNIFE
TheArt & Croft of TroumoSurgery

A carotidinjuryin Zone lll is uncommonand shouldideallybe idenilfed

preoperaiivey when youf control options are eiiher a Foley balLoon
caiheter nsertedintothe missiletract or angiographicocclusion.

But what if yo! encoLniera high iniernalcarotidinjuryduflngan urgent

exploration? Youcannotreachthe dlstalinternalcarotidwithoutoptimizing
your exposure.In the presenceof relentessback bleeding,yo! have no
iime for e aboratemaneuverssuch as subluxafion of the iaw Yourbest bet
is a rnuchsimoleralternative- a muscularand deierminedassistantarmed
with a suitableretractor Extendyour incisionto the mastoid process,
insert a retractorinio the upper corner of the wolnd, and have your
assistantpul rea ly hard,givingyou a few cr iical mi limeiers.lf this is not
enough,dividethe posteriorbely of the dgastic musce to gan more

When all you can see s the

bleedingorificeof the iiternal
caroiid,lgationol the arieryis
yo!r only fealisticopiion. The
injury is simply too high for
reconslructon.lf there isn'i
even enough length to ligate
or appLya melalc ip, consder
inserting a Fogarty catheter
inio the beeding orificeand
infaiing it. Apply iwo metal
c ips across the cathetervery
cose to lhe balloon,and cul
the catheterproximally,leaving
the permanently inflaied
balloon insde the artery. lt
may not be the most elegani
solltion ln ihe book - bui ii

Ligatingthe carotidis not I crime

 TlgerColniry
l4 TheNeck:Soforiin

Exsanguinationf rom bone

Have you ever seen exsanguinating
hemorrhage Jroma holein a bone?This is how a
vedebralarteryiniuryoften presentsin the open
neck.In the era of liberalangiography, ihis should
be a rare siiuaiionbecause the prefelred
rranagerent ol velebral arterv i'rlu.|esis
angjographic,not opetative. Occasiona ly,
you
however, will discover ihat the cafotid sheath
is Inlac-wlile audibleane'idlbleedrng 15spuning
from a hole in ihe pafaverlebral muscleslateral
and posteriorto il. Feel for the bodies of the
cerylcaLveriebraeto orieni youtself,and you will realizethat bleedingls
coming from the area of the iransverseprocesses lf you swipe the
paravedebral muscleslaierallywith a Petiostealelevaior,you are met wth
ihe !nforgetiableslghtof bdsk hemorthage from a holein a bone'ihe bone
beingthe transverseptocessof ihe iniuredceruicalvertebra

The severalingenioustechnlquesdescribedfor this exoticinjuryare a

sure sign lhal many crealivesurgeonshavefound ii a bafilingptoblem
Unfoolingihe injuredarteryin iis bonycana is a demandingtechnicalfeat
evenunderthe besi eleclivecircumstancesWe certainlydon'tconsder it
a feasibleoptlonin a bleedingpatent,
and neither should you. Proximal
conirolof the injuredarteryai ihe base
of ihe neck will not conirol backflow
from the brain.

Here, agan, the simpest solulion

is ihe besi. Pushinga piece of bone
wax inio the bleeding hole usually
works like magicl lf your facilityhas
angiogfaphiccapabilities,immediate
postoperaiiveangiogramwiih embol_
izationof the injuredvertebralarieryis
anothefoption.

Usebonewaxto pluga hosingvertebralartery

 TOPKNIFE
TheArt & Crofi of TroumoSLrrgery

The esophagus

Thereare two routesio

the cervical esophagus,
going either medial or
lateral to the carotid
sheath.The nredialroute
is a naturalcontinuation
of
carotid exploratronand
probablythe one which
youaremostfar.iliarwiih.

Before exploring the

esophagus, ask ihe
anesthesiologistto insert
a large-borenasogasiric
tube to help you identifythe esophaglsby palpatingthe tube in a hostile
operativefield.The esophagusis locatedslighilyto the left of the midline,
makingit easierto explorefromthe leftside of the neck.

Retract ihe conient of the

carotidsheathlaterallyand enter
the plane between it and the
trachea. You will find the
esophagusbehind lhe tfachea
and anieror to ihe spine. Full
exposure of the esophagus
requires you identify and divide
three structuresihai cross over
the esophagus:the omohyoid
muscle,middle thyroidvein, and
inferor thyroid ariery. The
recurrentlaryngealnerueis rarely
identified in the jnjured hosiile
 TlgerCowiry
l4 TheNeck:Soforlin

The otherapproachto the esophagus,goinglaleralloihe carolidadery,

is a "back door" approach,Llsefulwhen a large hemaiomain the caroiid
sheath obscufes ihe anatomy Retract the caroiid sheath struciufes
mediallyinsiead of laterally,and enier ihe plane between the carotrd
sheathand the cervicalspineto find the esophagusYour work space is
limited,but you are Iess likelyio causeiatrogenicdamage.

Approachthe iniuredesophagusth.ougha fiont or backdoor

Esophageallniutiesare noi easy to idenlifybecausethe esophagus

doesn'i have serosa. lf you can'l be sure there is an injury,goide the
anesthesiologistto pull ihe nasogastric tube to the level of your
expLorailon,flood ihe operatlvef eLd with saine' and ask the
anesthesiologst to inllate ihe nasogasiriclube with air' Waich for
emergingair bubbles.

The most worrisomeaspect of an esophageaexPotaiionis noi what

youcan seeandfeel, bui whatyou cat'l Is therean injuryto the otherside
ol ihe esophagus?To ihe posieriorwal? Wiih limitedexposure,it is easy
lo miss such an injury.lf you suspecta hoLeyou can 1 see' nerearo your
oplions:

a Contralateral througha separateincsion'often your

neckexploration

a Intraoperatveesophagoscopylo look for an iniurylrom insideihe

lumen,
a Mobllizethe esophagusby bluntlydevelopingthe plane betweenit,
the tfachea anieriorly, and the anterior longitudinal igaments
posteriorly.Hook your finger (or a Penrose drain) around it and
inspecl the contralateraland posteriof aspects However, this
maneuvers more dltficultlhan our descriptionleadsyou to believe'
especialLy if you ate trylngto do il thro!gh a right-sidedneck incision
Unlessyou have deceni experiencewith esophagealsurgeryidon t
uselhis option.Youmaycauseiairogeniciniuryto the esophagusand
fecurrentlaryngealnerves,as well as devascularize the irachea
 TOPKNIFElhe Ad & Croft olTroumo Surgery

Regardlessof the optionyouchoose,the keytacucalprincipe is io be

sureaboutthe hiddenaspectsof the esophagus beforeconcludng youf
exDtoTaIlon,

Worryaboutthe hiddenaspectsof the esophagus

After identifyingan esophagealinjury,careiullyassess the extentof

damage.[,4ucosal damageis ofien moreextensive thanihe apparentinjury
lo the muscularis.Conservatively debride the wound to obtain healthy
edgeson all sidesand repairit usingone or lwo ayers,Our preferenceis
a singlelayerrepar usingan absorbablemonofilament suture,[,/uchmore
impodanlthan the numberoi layersls precisedefinltonand meticulous
aDoroximation of the mucosaldeiect witholt tenson.

Always isolateyour esophagealrepairfrom oiher suture Ines. lf you

have also fixed ihe caroiid adery or the irachea, rememberthat the
esophagearepar s the one mosi ikelyto fa L When il fails - lt may take
yourotherrepars wih it. Don t et it happen.lnierposea well'vascularzed
chunkof healthyrnusclebetweenthe esophag!sand anyadjacenisuture
lines.The strap musces,ornohyoidor slernalhead of the SCM can each
be transectedclose to their inferiorattachmenisand ihen used to keep
vour suturelinessafev aoart.

Whal is ihe danragecontroloptior for the cervicalesophagus?Srnce

the aim is to preventan uncontrolledeak, the bail oui soluton ls exterral
drainage.lf the injuryis naccess ble (e.9. high or posteriorin the
hypopharynx), just drain t. lf there is no distalobstrlciion,the fisiulawil
rapidy close.

When you cannotsafelyclose the deiect becauseit is loo large, the

operaiionwas de ayed,or you haveto bai out, eitherdrainor exteriorizeit
as a latera esophagostomy.This s pariicuLarlyrelevanl when you
encounter combined njurles to the esophagus and lrachea, where
creatifgtwo high-risk suturelnes is askingfor troube. Repairing the
airwayand divertrngihe esophagusmay abe safer option.

A quick and easy bail out optior that has worked for us is to rnserla
lafgesuctjondrainirio ihe defecl,rapidlypurse'siringthe esophageal wall
 14TheNeck Soforiin TigerCounlry

aroundit and bring ii out ihroughthe skin Whateveryou chooseas your

damage control solution, fememberlan uncontrolledesophageaLleak
meansmediasiinitis and death;a controlledflstulameansa longerhospLtal
stay with a good chanceot recovery

Bailout by creatinga controlledesophagealfistula

The larynx and trachea

to lhe upperairwaycomein twolypes:smallandlarge Repair
lnjuries
small aceralionsof the larynx and trachea with interrupted3:0
monofilament absorbable suturestied on lhe ouiside Neveruse non-
absorbable suluresto thealrway.
repaLr

Largedefeciscannotbe simplyapproximated withouiienson because

part of ihe cariilageis missing.To obtaina good outcome'you are well
advised to gei early help ffom an ENT colleague They have more
experience with the upper airway and will ultimateLyrnanage any
complicatlons.

Severaldamagecontroloplionsfor uppef airwayinluies are availabl-".

You can simply push ihe endotrachealtube Past the injuted area to
eliminatethe air leak,leavingthe injuryalonefof a delayedreconstruciion
Anotheroplion is tracheostomy.Insertinga itacheostomytube througha
traumatic tracheal defect is not a good move under electlve
circumstances.li is, however,perfectLyaccepiableas a bail out option
whenthe patienthasotherife-threatening iniures,orwhenyouatefacing
a compex Inluryon yourown.

Transcervicaliniuries

How shouldyou approacha peneiratinginjurythat crossesthe neck

from sldeio-side?Transceruica!injuriesmay requirebiLaierdexpLoraiion
Rulingout an injuryto the oiher slde of the esophagusor trachea by
irtfaoperaiiveendoscopy,while iechnicallypossible,is logisiically
 TOPKNIFEThe Ari & Croit of Tfaumo Suraelv

To explore a transcervical
penetration, we prefer a lJ
ncjsion,the ceryica equivalent
of a clam-shel thoracotomy.lf
you spend a few minutes
deveoprng a superror
skinfap in
the subplaiysmaplane (as you
would do in a thyroidectomy), \ - l
yougainmaximalexposure of ihe \\.r11
bilaieral neck, mlch like ifting
the hood of your car to look ai
lhe engine. Exposure just
doesn'tget any betterthanthis.

Liftthe hoodoff the neckwith a U incision

Finishing up

Havea good look at the edgesot your ncisionin searchof superlical

bleeders.In the neck, a smal muscularbleedercan easily lead to a
postoperaiveexpandinghematomaand the need for urgent re-
exploration,Inspect your suture lines and make sure they are nicely
separatedby viablemuscle.

We stronglyadviseyou dra n everyneck exploration {or lraumausinga

closed suctiondrain.The mosi commonlymlssedinjuryin the neck is a
smallesophagealperforaiion.Your dra n will conved a poientlaldisaster
inlo a minorproblem.Jf drainng an esophageal sutureline,bringyour
drain out anierorlywiihoutcrossingoverthe caroiid artery'drains have
been knownto erodeinto lt. The only ayeryou haveto approximate deep
to the skin is the plaiysma.Thencose the skin and you havesuccessfuly
compleiedyour safariin tiger country.
II
14Jhe Neck Sotariin Tigea'CoLtniy
t

) Lift.thehoodoffthensckwitha U incision
TOPKNIfElhe Art & CrclJiof lroumo SLJrgery
 Chapter15
PeripheralVascular
Trauma Made Simple
Eoerything shoulil be fia ile as
simpleaspossible,but not sirftpler.
- Alberi Einstein

li you thinkyou know whai a bloodymesslookslike,a closeencounter

with a hosinggroin wi I haveyou think agan The patientis n shock,with
most of the bLoodvolumeeilherlelt at the sceneor all overihe paranredlc
compressingthe bleedinggfolnfor dear life.Sinceihls is one oJthe most
spectacularpenetratinginjuries,ii is easyto forgei priotities,r.ake critical
errors,and lose ihe patlenlin the midstof the chaos

In ihis chapier we try to bridge the wide gap between the neat
ilustrationsof vascularexposuresyou see n books and the harshteality
of the OR, where the paiient is bleedingand all you can see in ihe
operativefield is tfaumaiizedmuscleand lots of hernaloma.Bridgingth s
gap is especiallyimportantfor surgeonswho don t do periPheralvascular
work on a regularbasis but are called upon to conifo and repair the
occasionalarterialinjury.Our key messageis that the injufed artery is
alwayspart of a wo!nded patienl,and the patient'soveralltraumaburden
oflFn orcraies1ow yoJ approachlhe vdscuar 'njury

Caining controlof the hosinggroin

Obtain iemporarycontrol of ihe bleedlng groin wiih local pressure

appliedby an enthusiasiicassistanior a Foleycalheterin the tract Once
in lhe OR, you needproximalconlroland havethreeoptions:

i Laparoiomy- if there is urgentindicaiion,go into the abdomenand

controlthe ertFrnaliliacanery in the pclv;s
 TOPKNItETheAri & Croft of TroumaSurgery

a Reiroperitonealapproach-
expose the exiernal i|ac
artery through an obljque
lower abdor.inallnclsron
approxrmately2cm above
a.d pafallelto the nguinal
ligameni.Incisethe apo-
neurosesof the externaland
internalob|que, and open
the iransversls abdominis
and transversalisfascia io
exposethe preperitoneal fat.
Gentlecephaladretraction of
the peritonealsac will bring
you to lhe external iliac
artery.Thisapproachavoids
laparotomy,but takes time,
so is farely used in the
bleedingpatieni.
a Verticalgroininclsion- the simplestway to gain proximalcontrolof ihe
nosrnggrorn,

So much for the good news.The bad news is that evenwith proxima
control, the paiientcontinles to beed, albeit at a slower rate. lf back
bleedingis noi very brisk and you can identifythe key structures,use a
combinatonof sharpand blunt disseciionlo exposethe fer.ora vessels.
Bluntdisseciionis saler in hostileterriiory.You want to avoiddamageto
the femora nerve,and yo! cannotcut the femoralnervewiih yourfinger

lf you can t see whatyou'redoingbecauseol briskback bleeding,walk

the camps (Chapter9). The solrce of persistentback bleedng is often
the deep femoralarterythat must be identifedand controlled.When you
succeed,breatha sgh of relief;you havesuccessfullydeat with one of
the cobrasoi traurnasufgery.

Gainproximalcontrolof the hosinggroin

 l5 Peripherolvsscu o. TrounroMode Simple

A quick tour of the femoral tdangle

You are pfobably{amiliarwith

the femoraltrianglefrom visrts1o
lhe groln in electivevascuar
procedures.Make a verticalskin
incisionover the femoralpllse, if
present. otherwise, place yout
incision halfway between the
pubic tubercle and the anterior
superiorlliacspine.Approximately
one-thirdof the incisionshould
extendabove the gfoin crease
This is not the timeto be hesLtant
or minimally invasive.

Exposingthe femoralvesselsin a
war zone is not easy. You have to
identifyand inciseiwo fasciallayers:
the fascia lata and the femora
sheath. Cut lhe {ascia lata
longitudinallylo enter the fat of the
femoral triangle and insert a self-
retainingretractof.Yourbestfriendin
the hosiile groin is the inguinal
ligament, and the exPerienced
surgeonmakesa poinl of idenii{ying
t early.Palpalethe faity content of
the trianglewith an educaiedIinger
Feel for a pulse or, if absent,for a
tubular structure in the fai ln the
pulselessgroin,you often encounter
musclebeneaththe fascia lata.This
simplymeansthai you are too latera,
overthe iliopsoasmuscle,so redireci
your dissectionmedial)/

The inguinalligamenti5 youronlyfriendin a hostilegroin

 TOPKNIFE
TheArt & Croft of TroumoSurgery

Next,open ihe femoralsheaihio jdentifyihe femoratartery.Reposition

ihe self-retajningretractorat a deeperlevelor add anotherretractor.Stay
on top oi the arteryin ihe pedadventitial
plane.lf you deviater.edially,you
may be greetedby a gush of dark bloodfrom the fer.ora vein.If vou strav
laterally,
you may injurethe lemorainerue.

lsolaie and control the

commonlemoralarteryand iis
branches.While the common
and superficial femoral
arteries can be readily
identifiedand encircledin the
proxmaland distalparts
of the
incision,isolatingthe deep
femoralartery can be difficuli
for surgeonswith few 'groin
hours.' The lateralfemoral
circumflex vein is ihe most
keacherousvein in the groir.
It crossesimmediatelyin froni
of the proximaldeep femoralartery in ihe crotch betweenthe deep and
supedicialfemofalartery.lf you try to exposethe deep femoralarteryby
unroofingit, you soon encounterbrisk venousbleedinolrom ihe iniufed
vein.Avordils-rhis
;i6;iJiiiiruaTioi-ii rar'tcteiihantryirgto.ixir.oo
not disseciout the deep femoralartery,plainand simptel

The origin of the deep

femoralarteryis markedby an
abrupi change in the drameter
of the commonfemoralartery.
Take a vessel ioop and pass
one end from lateralto media
underneath the common
femoral artery weli above ihe
bifurcation.Grab the otherend
of the loop and pass it from
medialto lateralwell belowthe
bifurcation.Lift up bothendsof
 I 5 PerlpheroVosculorTroumoMode simp e

the loop io discoverthai you have neatlyisolatedthe deep femofalafiery

withoutdissectingit out

Don'tdissectout the deepfemoralartery

Gettingaro!nd ihe groin is r.ore difficultin the presenceof a szeable

wiih
hemator.;.We call it a hosiilegroin,andwhenyou comeface_to_face
it, youwillsee why.The anatomyis distorted'the tlssuesare suffusedwith
blood,and a bu ging hematomais lookng up at you in toial defiance

Here,we wouldlikeio lei Yotr

ln on a litlletradesecrei Forget
lhe femoral vesselsl Instead,
focus on findingihe inguinal
ligameni.lt soundscrazy_ blt t
works. The inguinalligaments
an anatomicalbarrier {ChaPler
3), and i{ you ldentirythe lower
edge of the ligameniand cul ii,
youwillfind yourselfin the virgin
lower reiroperitoneum.Now,
you can easlly ideniify ihe
exiemaliliacvesselsimmediaiely
abovethe groin.

Thereis, however,a less destrucilveway

to clamp lhe femoral vessels above the
inguinal gameni.Take blunl Mayo sclssors
and make a hole in the inguinalligameni
approximately 1_2cmaboveand parallelioiis
edge.lnseria nafrowdsep reiractorio keep
the space open. This brlngs you into the
hematomaJfee retroperiioneum wLthout
dividingihe inguinalligament You can now
use ihis hole io easily palpateand sa{ely
carnplhe externalllacarieryabovethe groin.
Allthis is verycool,bui if you are pressedior
iime and ihe groin is aciivelybleeding,don t
 TOPKNIFE
TheAri a Croftof IroumoSugery

hesfiateto cut ihe inguina]Iigament.lt is a smallpriceio payfor expedieft

proxmal conlrot,

Controlthe commonfemoralarterythroughthe inguinalligament

Considering youl options

As in any other operationfor trauma,you now have to choose an

operative profile. Consider ihe patienis ovefall trauma burden and
physology,as well as the operativecircumsiances(Chapter1). Are you
operatrngrf a universitytraumacenteror in an mprovisedfield hospitaln
a war zofe? How comfortableare you with vascularwork? Balanceall
theseagainstthe feparfoptrons.

Darnageconiro optionsfor ihe femora vesselsare temporaryshunting

or ligaiior.A temporaryshunti. the commonor superficialfemoralartery
is an excellentdamageconirol so ution to maintaindistatperfusion.We
strongly recomr.endyou do a pre,emptivefasciotomyto give the leg
added prolectronin case of earlyshunl fallufe(Chapler3). On v6ry rare
occasionswhen a shuft is not an opUon,ligatingthe lemoratartery is a
valid aiernatve. In fact, you can igatethe slpedicial femoralartery in a
young healthy paiient with low risk of llmb loss, pfovided collateral
ciculationviathe deep femofalarteryis irjtact.In the greai nraioriiyof bail
out siluations,a shuntis a nruchbetteroption.

Whenoperaiing ln damagecontrolmode, fixthefemoralvein

onlyifyou
can get awaywith a simplelatera repah Don t hesitateto ligateihe vein
if the injuryreq!ires an),thingrnoreelaboraie.

Shunt+ fasciotomy= bailout fo. femoralarteryiniuries

Preservingthe deepfenroralarterywhen possible,is an impodant

principle.Yourabilityto reconstruct
ihe bifurcation
dependson your
vascuar expefenceandtechnical repertoire.
Onewelfknowntrickin the
 r5 Perlpherolvosculor TroumoMade slmpe

face of extensivedamage to
the bifufcationis to join the
stur.ps of the superflcialand
de6p femoralarteriesside{o-
sideto createa shortcommon
arterialtrunk before inserting
an nterposltiongraft. This
sparesyouthe awkwardjob of
implaniingthe deep femora
arterylnto the gra{i.
I
lf the posteriorwall of ihe
injuredferioral arteryrs iniact,
do a patch repa;r lf the artery
is transected,inierpose a
syniheticgrajt or a reversed
saphenousveinfror. the oiher
leg. lf the arterialand veirous suture lines afe immediatelyadjacent,
interposeviablemusclebelweenthem to preventan aitoriovenous fisiula
We do not lnsert iniePosition grafts lnto the femoral vein, but many
surgeons oo.

Whateveryo! do to fx ihe femoralvessels,plan your reconstructLon

wilh soft iissue coverage in mind lf you cannot cover the arterial
reconstructon with well-vasculariz€dsoft tissue (e,g swinging the
sarioriLrsmuscle over the repait),call someonewho can An exposed
arterialsuiurelineis a tickingtime bombthat will blow up in vour tace

An exposedvascularsuturelineis a tickingtime bomb

The superficial femoral afiery

art6ryexposuresis
Not surprisngly,a descrpiion of superficialfemoraL
not found ir most vascularsurgicalatlasesbecauseit is rarelylsed in
electve surgery.Here'show it's done.
 TOPKNIfElhe Art & Crofl of TrouraoSuoerv

Slightlyflex and
externally rotate
the patieni's eg,
supportrng t on
foldedtowels.When
working above ihe
knee, supportihe
leg belowthe kneeto avoiddisiorlingyourwork space.Makea longitudinal
incisionover the anteriorborderol ihe sartorils muscle,extendingit well
proximaltothe injury.lncisetheskincarelullyto avod accidentallytransecting
the saphenousvein.Open
the superficialfascla and
identify the sartorius
muscle,the gaiekeeperof
ihe super{icial{emoral
artery.Retractihe sadorius,
A,A eithef anieflorly (in the
upperand niddle ihigh)or
posterrorly(in the middle
and ower thigh), by
insertlng a self.retaining
retractor nto the wound.
Your target ls the flbrous
roof of Hunters canal,the
white fascia directlyunderneath
the sartoriusbetweenthe adductor
magnusandvastusmedialis muscles.Openil andyouarestaringat the
neurovascularbundle.Carefully
freethesuperficial
femoralarteryfromthe
adjacent vein and pay
special atteniion to the
saphenousnerve that Ls
pad oi the neurovascular
bunde and can be easijy
damaged.As with any
vascuar Injuryi$an your
dissectionln v rginterriiory
proximalto the injury and
proceed disialy toward
the injuredsegment.
 l5 Peiplrero Voscu or Troumo Mode Simpe

What are your repair optons? YoLlmay elecl to inserta shunt if you
needto bailout or if you decide (withihe orihopedicsurgeons)to achleve
bone alignmentpriorto arterialrepair.This is genetallya good ideasince
sewinga graft in an unslableflailinglir.b is somethingyo! shouldavoidlf
possible.When the superficialfemoral artery is iransected' Insert an
graft.
interposition

Thesartoriusis the gatekeeperof the superficialfemoralartery

Popliteal repaks the easywaY

Treatthe poplitealartery wiih the resPectit deserves lt is the leasl

accessiblevesselin the lowerex?emlty,and ihe collaleralflowaroundthe
kneeis insufficenitosustainviabilityofthe lowef leg ifflow in the popliieal
arteryis inierrupted-Evenioday,popliteaarterytraumacatrieslhe h ghest
inb lossrareo'ale\kemry vascuarnrures.

Always begin a poplitealrepair with {asciotomy,even il you are an

exiremelysmooth operatof.lf there are no associatedlnjuriesihat may
bleed,givesystemicheparin.[/any pop iiealrepairsfa becauseol cotted
not becauseof a technlcalflaw
dista mlcrocirculation,

Treatthe iniuredpoplitealaderywith the greatestrespect

The safe and sound

route to ihe injured
popliieal artery is the
medialapproach.Make
an incislonin the lower
th gh alongthe palpable
groove belween the
vastusmedialsandsart-
orius muscles.Palpate
bordero{ ihefemurandinciseihe deepfasciaposterior
the posterior to ii,
you
bringing s?aightintothefatiy popliteal
contentofthe lnserl
lossa. a finger
andpalpate arteryagainsitheposteioraspectof
the pulseof ihe popliteal
 TOPKNIfETheAri & Croii of TroumoSurgery

the fe.nur The posterior

edgeof lhe boneis the key
anatomical landmark to
ihepopliteal
identify vessels,
both above and below the
knee. Now ideniify,dissect
out, and encfcle the above.
knee popliieal artery. The
three major pitfalls in this
dissectionare injuringlhe
closely adherenl popliteal
vein,cutlingthe saphenous
nerve, and mislakingthe

Find the poplitealartery immediatelybehind the bone

Expose the distal

Pophteal segment
thfough a sepafate
incision that runs
approximatelylcm
behindthe borderof
the tibia,begrnningat
the levelof the knee
rmmediaie y posterior
to ihe medialfemoral

Asain,bewareof injurng
the saphenousv€inthat lies
imrnediatelyposteriorio your
incision.Cutting lhe deep
fascrarevealsthe fal of the
distalpoplilealfossa,where
you find the neurovascular
bundle immediatelybehind
the bone.The first structure
 Voscuor Troumo Mode smpe
15Periplreroi

you encounleris the pop itealvein,and you haveto carefullydissectthe

arieryawaylrom rt.

So niuch for proximaland distalcontrol.But how are you golng to lix

ihe injuryitsel{,an iniurythat siill remainshiddenbehindthe knee?Well'
you can do it the hardway or the easyway

The hard way is the traditionalful! poplitealexposlre' the one you

should describe in your Board Exam becauseihls ls whai examLnerc
expecito hear.li entais joiningihe medialincisionsaboveand belowihe
kneeand dividingthe tendinousaitachn-rents ofihe posleromedialmuscles
(sariorius,graciis, semimembranosus' semltendinosus)' as well as the
attachmentof ihe medialheadof the gasirocnemius ln praciice'grab the
cauieryand blazea trail oJ destruciionbetweenyour proximaland distal
incisions,blastingany iendonihal stands betweenyou and the poPl*eal
artery.Ii soundsllkea searchand deslroymissionbecauseit is Bytheiime
you flnish,it is not a prettysight,but you can get io the arteryand fix it

There is a simpleralternativelnsiead of exposingihe injuredartery,

bypassand excludeit. You akeadyhavelhe proximalanddistalpopliteal
segmentsloopedand ready Evenif the poplitealveln s injured'ii doesn't
matter,You don t haveto reconstructit io achlevea good outcome The
notionthai yo! do ls jusi anothersacredcow that has been slaughtered
by curreni data. Your mosl expedientsoluiionis to harvesta pLeceoT
saphenousvein from ihe other thigh, teverce ii, and inseri ii as an
lnterposiiiongraft belween the proximaLand dista poplitea artery,
excludingthe injuredsegment.

Bluntlycreaie an inter_
condyaf iunnel between
ihe proximaland disial
Do a longiiudinal
lncisions.
arteriotor.yin the Proximal
popliiealarteryabovethe
knee, hook !p the
reversedvein endlo-side,
and ihen doubLylLgate the
adery immediatelYdistal
 TOPKNIFE
TheA.t & Croit of TroumoSurgery

to the anastomosisto excludethe inluredsegment.pass the pusating

graftthroughihe tunnel,and hookit up to a similararterioiomyin ihe distal
pop itealarierybelowthe knee.Thenligatethe arteryimmediately proxima
to the d stal anastomosisto completethe excusion,In an obese pattent
with a deep artery,ii is easierto transectthe proximaland drstaloopliteal
arreJ.oversewrhe endso l-F e.ctLdeo<eg-ent.a.ld .henhoot up -he
vein graft end-io-end.

The huge advartageof this approachis simplicity.you don t haveio

dealwith the inj!red segmentai all.The on y vatidreasonto takedown the
ligamentsand exposeihe poplitealfossa is ongoing bleedingfrom the
njufedsegmentdespiteexcluson, a s tuaton we naveyet io encounter

Bypassand exclndethe iniuredpoplitealartery

Below the knee

Reconsiructinga iibial arteryin a patieniwiih a blunt bumper injLrry

thai includesa fracturedlibia and f bula is an experienceI ke y to remain
etched n your memory.Imagne spendingthe beiter part of an on-call
nrghttrying to bridge two spastc noodlesin a soup of blood, broken
bones, and torn nuscl€s. Answeringthe followingihree quesiionscan
he p makethis experiencemuch ess traumaticfor you and your patient.

1. ls th s escapadereallynecessary?One of the rhreeleg arieriesopen

all the way down to the foot rs good enough.The iradiiionaiteachng
that panents with blunt trauma need two open vessels s an
unsubstantiated urbanlegend.Remember- if one of the threearteries
is beedng, the solutionis noi surgicalexptoraiionand ligation,b!t,
rather,angiographicocclusionol the bleeder(unlessangiographyis
foi avalabe).
2. Do you have the required infofmaiiof for a safe trip? Staring a
vascularexploration beow ihe knee wthout a ctearangographic
delineaiionof the inluredsegment is tike stading the Dakar Rally
witholt a map. I\,,lake
everyeffortto obtaina formalangiogram.lf you
 l5 Pe.ipherolVoscu ar TroumoMode Simpe

popliieal
are forced to run to the OR urgenily'begin by exposingthe
stlb_
artery below the knee and shootingan on_tableangiogramA
optimalangiogramcan send you on a lengihy exploration ot what
turns oui to be an intactaitery in spasm
3. Where to begin?The popliiealfossa below the knee ls an excellent
siartingpoint becauseyou can always{ind the ariery there, even if
you havelilte vascularexperiencell is v rginterrltory,the vesselsate
large, and you can ideniifythe neurovascular bundle and follow t
disialy.

Retracl the medial

head of the gastroc-
nemius posteriorlyand
exposethe edge of the
soleusmusclearchlng
ovef the popliteal
vessels.Hook a finger
underneaththe r.usce
and detach ii trom the
tibia. This opens the
sPace,alowlngyou to
place a self-retainlng
retfactorin the wound.
Proceeddistallytoward
the injury by taking
down the atlachmentof the soleuslo the posterioraspect of the Ubia
Look for ihe anteriortibialvein as a markerof the iake-offof the anienor
artery.Further
tibiaL
distaLly,identifythe
bifurcation of ihe
tiboperoneal irunk
into the postenor
libial and peroneal
arteries,wherethe
formeris the more
superfic al vessel.
 TOPKNIFE
TheAd & Croli of TroumoSurgery

Exposeihe anteriortibialarteryln the mid'and lowef leg ihroughyour

anteriorfasciotomyincision,lnsert a self-retaining
retractorbetweenthe
tibiaisaniefor and the extensorhallucislongusmlscles,and find the
neurovascu ar b!nde deep down between the musces, on the
InlerosseusraemDTane,

Before you begin a vascularexplorationbelow the knee, slrongly

considerus ng a proximapneumatciourniquet aboveihe knee.Nothng
is morelrustratrngthan tryingio identlfyand isolatethe smalland frag le
vesselsof the lowerleg in the presenceof activebleeding not io meniion
ihe ncreasedrsk of iairogenic njury io other eements of the
neurovascular bundle,

Whch ariery shoud you reconstruct?Always go lor the most

straightforwardso ution n the mosl accessibe ariery and take into
accountsoft tissuecoverage.lMostoften,th s lranslatesinlo reconstruciing
the posteror libialadery.In a badlyinj!red eg, be preparedto spend some
time lookingfor the dstal end of the transectedvessel,which may be
dtficuli10 fnd. In most instances, yourbest reconstructive optionis an
interpositiongraft usinga reversedsaphenousveinfrornthe otheranke.

is goodenough
Oneopentibialartery

The axillaryartery
To gain rapld access io the,4&iy," ^,--
proximalaxilary artery,you have io ;r;1 ,r 1, ,.a^or)
go ihrough the pectorais major
muscle.Abduct the arm and make
an nfraclavlcular incsion extending
from the mid-clavicle io the
deltopectoral groove. This trans- i) ,-.4-'
-
pectoral rouie is an extensle
exposure.You can extendit distally
along lhe dellopectoralgroove.
Dissectionbetweenthe delioid and
ihe pectoralisr.ajor, combned wilh
 Modesimpe
r5 Peipheravoscuarlroumo

lateralrevactlonof ihe cephalicvein, will revealthe clavipectotalfascra

containingthe neurovascularbundle Fudher distal exienspn Into the
groove betweenthe biceps and the tticeps muscleswill get you to the
proximalbrachialadery

Cul down io the

pecioral lascia, divide
it, and then spreadthe
pectoralismajor fibers
by insedrng closed
Mayo scissorsinio ihe
muscle and oPenjng
them pefPendicularto
ihe fibers lo nrake a
hole. Underneath you
find the pectotalis
minor
and the claviPectoraL
fasciamedialtoll. OPen
the clavipecloralfascla
and dlssectln the axilLaryfai to identifythe axillaryvein,the gatekeepero{
lhe ar lla.Tl^eaneryis oeep and supetiorIo it To opt'nizeyou'worl
space,get the pectoralismlnormuscleoui of the way eitherby retractrng
or dividingits upper aitachr.ent1o ihe coracoid process To
ii lateraiLy
safelymobilizethe axillaryartery,you musi fitst identify'clanrP,and cui the
thoracoacfomialartery,one o{ the only arterialbfanchesin the body io
come siraightat you when exposingthe parenivessel

Your damage conhol opiions for axillaryartery iniuries are shunt

insertionand, less commonLy, ligationand fasciotomyAmple collaterals
aroundihe sho!lder wilLpreventcriticaldistal ischemiain most patienis
wrh an ir.e Jptedari,a-yalery but rFuonstrLcion rusnga saohelors
vein gra{i hawesiedfrom the ihigh) is a betier optionif {easible

major,not aroundrt
the axillaryarterythroughthe pectoralis
Approach

)-
'.,
.,;,..,
.|trr.",r..*,J
,,,y
'q'. l.J lr-,- il-^r
 itr.\.v./-
TOPKNIfETheAd & Crofl of Tro!mo Surgery

The brachial artery

The brachialairery s the most

frequentlyinjuredarteryin the body
and certainlyone ol the most
accessibe, Gain access to the
pfoximalartery via a medal upper
arm incision along the groove
between the brceps and triceps
muscles. Thisincisionsthe epitome
of extensileexposure,as it can be
easiy extendedboth pfoximallynto
ihe de topectoralgrooveand d stally
acrossih€ antecubtalfossa inlo the
forearm. Incise the deep fascia at
the media border of the biceps,

taking care to avold

iairogenic lnj!ry to the
basiic vein as it emerges
ihrough ihe fascia in ihe
lowef aspect of the
incision.Antefrorretraction
oJ the brceps will expose
the neurovasc!larbundle
envelopedin the brachial
sheath.The f rst siructure
you encounter (and your
landmark) is the median
nerve. Retract it genlly to
get t oui of your way.

Distalextensionof the medialarm lnclsionrs vra an S-shaped ncrsion

carriedacross the antecubitalspace disia to the skin crease.The distal
brachialartery and its bifurcationare located immediatelybeneathihe
bicepstendon,againrn cJoseproximiiyto the mediannerve.
 I5 Peiplrero Voscu or TroumoMocle simp e

The damagecontroloptionlor the brachialaderyis ligationand

whichisverywelliolerated,
fasciotomy, i{theiniuryis inthemid_
espocially
or distalarm beyondto the take'offof the deep brachialartery The
oefntverepairopton s a veir interpos:tion Jsingthe sapheroLs
gtaft
veinharvesiedabovetheankls.

THE KEY POINTS

) Gain proximalconirolof the hosinggroin

) The inguinalligameniis your onlyfriendin a hostilegroin'

> Don'i dissectout the deep femoralarterr'

) Controlihe commonfemoralarterythroughthe inguinalligament

) Shunt+ fasciotomy= bailout {or femoralarieryinjuries

) An exposedvascularsuturelineis a tickinglime bomb'

) The sartoriusis ihe gatekeeperof the superficialfemoralartery'

) Treatthe injuredpoplitealarterywith lhe greatestrespect'

) Findthe poplitealarteryimmediatelybehindthe bone'

) Bypassand excludeihe injuredpoplitealartery

) One open tibialartefyis good enough.

) Approachthe axillary major,not aroundt

arterythroughthe pectoraiis

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ll