Packing liver

place rolled packs in subphrenic and subhepatic space
avoid IVC compression
effective packing is a wrap not a sandwich
pack early (packing relies on clot formation)

if still bleeding despite packing:
technical error
packs do not control arterial bleeding:
inflow occlusion needed (in trauma usually venous)
if bleeding looks arterial despite inflow occlusion the hepatic artery may have an anomalous origin (left hepatic from left gastric in 15% Right hepatic can arise from SMA. Supra coeliac cross clamp will help)
if dark blood gushes from behind the liver: dealing with retrohepatic venous injury: divide falciform and push liver posteriorly to compress
Do not mobilise when there is a suspicion of a retrohepatic venous injury: you will lose control

If packs dont fully control bleeding: send to angio for embolisation

ED thoracotomy

Indication
penetrating trauma with less than 10 mins CPR
5th ICS sternum to bed down on to rib
cut down to pleura and through small area laterally then use fingers and scissors to extend
chest wall restractor
open pericardium (root of aorta to apex)
repair heart foley catheter or staples
clamp thoracic aorta
clamp lung root (can twist hilum)
rapid transfer to OT

Damage control laparotomy

Three dark angels: acidosis, coagulopathy, hypothermia

Indications
SBP<90
Temp<34
APTT>60
pH<7.2
Pattern recognition
Lactate >5
Inability to achieve haemostasis owing to coagulopathy
time consuming procedure (>90 min)
inaccessible major venous injury
life threatening injury in second location
planned reassessment of abdominal contents
inability to close abdomen

Aims:
Control haemorrhage: pack all quadrants
must control surgical bleeding definitively
pack medical bleeding
simple vascular ligation, balloon tamponade or shunting
perform rapid exploration
control contamination
staplers or tapes
don't waste time creating stomas
drain tubes for biliary or urological injuries
pack abdomen
perform temporary abdominal closure
avoids compartment syndrome

procedure
aim <1hr
warm theatre to 27
have packs available
prep from neck to knees
full length incision to fascia then through fascia
avoid sucker use initially
scoop out blood and pack abdomen

Definitive haemostasis
Splenectomy (can be done <2mins)
clamp mesenteric bleeding
nephrectomy
packing of liver and adjuncts
if unable to gain control: cross clamp aorta
control bleeding from visible vessels
consider temporary vascular shunts
Balloon occlusions of vessels
Can tie off IVC below renal vessels (consider lower limb fasciotomies)
drainage for pancreatic injuries
washout
Close: towel clips
Bogota bag
VAC
Remember angiography esp for pelvis and liver

When to reoperate
lactate <4
base excess >4
normalised coagulation profile

Relook
perform definitive operations before pack removal
restore intestinal continuity
'tertiary' survey

complications
most common is compartment syndrome (15%)
(renal failure occurs when pressure >25mmHg)
infection
-associated with packing itself, not just contamination. Also with hepatic artery ligation

Fasciotomy

clinical exam
intra compartmental pressures >30mmHg
perfusion pressure <30-40mmHg (ie DBP-compartment pressure)

Two incision technique
Anterolateral incision
15cm incision 2cm anterior to fibular shaft over anterior intermuscular septum
transverse incision is made over septum to allow access to both compartments
Visualise septum
identify superficial peroneal nerve near septum
Maintain tension on the fascia with a Kocher clamp
Open the fascia proximally and distally with Mayo scissors
Proximally aim for the patella and distally for the centre of the ankle to stay in the anterior compartment
Avoid straying too medially to avoid injuring dorsalis pedis
Lateral compartment fasciotomy is made in line with fibular shaft
Distally aim for lateral malleolus to stay posterior to the superficial peroneal nerve

Posteromedial incision
Deep and superficial posterior compartments
15cm incision
2cm posterior to edge of tibia
Once down to fascia, undermine to tibial edge: this will avoid long saphenous vein and nerve
Retract saphenous vein and nerve and release fascia over superficial compartment. Keep tension on fascia with a Kocher
Soleus origin is from posterior 1/3 of tib/fib and covers proximal portion of deep compartment
Detach soleal bridge to expose fascia FDL and tibialis posterior
Neurovascular bundle is between tibialis posterior and soleus
In the distal half of the tibia the deep compartment is subcutaneous: again releasing the fascia over FDL is required to access the deep compartment
Fascia is opened distally and proximally under the belly of soleus

Subclavian artery trauma

Anatomy:
3 parts
1st: origin to scalenus anterior
2nd: medial SA to clavicle
3rd: clavicle to medial pec minor

Area of SC artery to be exposed:
Proximal left: left lateral thoracotomy and supraclavicular incision or trapdoor
Proximal right (first portion): median sternotomy with right cervical extension
Second portion either side: Supraclavicular incision with infraclavicular extension (s shaped incision)
Right or left third portion: as above

clavicle may need to be disarticulated
If stable: perform trapdoor/left lateral thoracotomy
If unstable: left anterolateral thoracotomy, apply pressure apex pleural cavity, clamp origin
repair primary anastomosis or interposition graft

ICP monitor

Indications
GCS 3-8 and abnormal CT
If normal CT, rate of elevated ICP is 10-15% so add:
GCS <8, Normal CT, and two of:
Age >40
SBP<90
Inability to monitor neuro status eg GA

Types
Gold standard is fluid coupled EVD (can also drain CSF, but can get blocked and be hard to place in high ICP where ventricles are small)
Intraparenchymal Bolt is a fibreoptic non fluid filled system

Bolt
Place on Right side (usually non dominant)
Mark Kochers point (2-3cm lateral to midline (approx mid pupillary line) and 1cm anterior to coronal suture
Need to make small incision in dura

Complications
3% major haemorrhage rate
Infection rises significantly after 5 days

Intra abdominal pressure monitoring

Foley
Pressure transducer zeroed at level of symphisis and inserted into aspiration port of IDC
Clamp catheter
Instil 50-100mL of saline
Can measure indirectly by placing U shaped loop in Foley with apex of loop at level of symphisis (10mmHg = 13.6cm H20)

Abdominal compartment syndrome occurs in a graded manner
Anuria is usuallt present by 30mmHg

30cm H20 (22mmHg) is a critical level requiring therapy used by some
Clinical judgment is required
Sequentially rising measurements in the face of pulmonary, renal and cardiovascular compromise may necessitate decompressive laparostomy

DPL

midazolam/morphine
LA infiltration with adrenaline
3cm vertical midline incision 2cm below umbilicus (above if preganant or pelvic fracture)
Dissect to linea alba (self retainer helpful)
If kit, grasp and lift fascia then insert needle 45 deg inferiorly, pass into peritoneal cavity and slide over wire. Aim for rectovesical pouch
Aspirate, if 10mL blood found then arrange laparotomy
If not then infuse bag of saline in but do not allow to empty completely.
Put catheter bag on floor: need to get 300-350ml back for analysis
Controversy over what is positive: >500WCC/mm3 suggests small bowel or colon injury
>100 000 RBC/mm3 widely accepted but some have used 20 000

Diaphragmatic hernia repair

Trauma laparotomy
1 Ethibond figure 8 interrupted suture
Right side may be better to approach thorascopically

Open splenectomy

Preop
Vaccinations: meningococcal, haemophilus, pneumovax
steroids in ITP
Antibiotics

1.Position patient supine with the left side raised in a bean bag.
2.Make a left subcostal incision.
3.Start by mobilizing the splenic flexure.
4.With the left hand retract the spleen medially and divide the lieno-renal ligament until the spleen is free from Gerota’s fascia and the diaphragm. This manouvre will deliver the spleen into the wound.
5.An alternative approach is to begin anteriorly and encounter the left gastro-epiploic vessels outside the arcade along the greater curvature and ligate them. Within the posterior wall of the lesser sac, you should be able to visualize the splenic artery which can be controlled with a silastic sling. Continue division of the gastro-splenic ligament and divide any short gastric vessels you encounter.
6.Ligate the main trunk of the splenic artery at the hilus. (spleen will shrink 15-20%)
7.Search the posterior aspect of the splenic hilus for the tail of the pancreas and dissect it away, ligating any vessels to the gland. This will give the spleen an opportunity to decrease in size.
8.Ligate the splenic vein at the hilus.
9.Examine the greater curve and if there is any suspicion of damage, invert the stomach with Lembert sutures.
10.Lavage and close.

Operations for splenic trauma
1.Preservation techniques
oSuperficial injuries – APC
oTransverse fractures – splenorrhaphy or hemisplenectomy
oLongitudinal fracture – pedicled omental patch
oStellate fractures – suture/tisseel duo or vicryl mesh wrap
2.Splenorrhaphy following complete mobilization by debriding edges and suturing lacerations between Teflon felt or a vicryl mesh wrap.
3.Partial splenectomy – complete the division of the remaining spleen ensuring that it will be viable, ligating vessels on the cut surface and then repair cut end of organ between Teflon felt.

Operations for pancreatic and duodenal trauma

Duodenum
•Primary repair +/- gastro-enterostomy
•Roux limb
•Jejunal serosal patch
•Damage control oversew with catheter duodenostomy, diversion of stomach by stapling across D1 without division and gastrojejunostomy (+/- T tube drainage for associated CBD injury as a ?Hugh-Devine type procedure)
Pancreas
•With Lucas grade III injuries or extensive damage to the pancreatic head, perform debridement as a damage control procedure or Whipple if well.
•With Lucas grade II, debride/drain (usual for grade I), a roux-en-y longitudinal pancreaticojejunostomy or distal pancreatectomy

Cricothyroidotomy

1. Position patient on head ring and sandbag between shoulder blades.
2. Prep and drape.
3. Grasp the thyroid cartilage between the thumb and middle finger of left hand and palpate the cricothyroid membrane with the index finger.
4. Make a transverse incision at this level about 2cm in length after infiltrating with LA through skin, fascia and cricothyroid membrane.
5. Insert curved Mayo scissors into the opening and spread to enlarge.
6. Insert a cuffed Tracheostomy tube Size 8 (8mm internal diameter) into the lumen and secure as above. No need to close the wound.

Tracheostomy

All patients will have ETT
Mild neck extension
Towel under shoulders, Head ring
LA infiltration
Prep and drape
Collar incision 1-2 finger breadths above sternal notch
Incise platysma
Separate strap muscles (sternohyoid and sternothyroid) in midline
Keep dissection exactly in midline to avoid bleeding
Divide isthmus with diathermy to expose second and third tracheal rings
Horizontal incision between rings with cricoid hook in place (Stomal size is directly related to tracheal stenosis, avoid 1st ring as risk of subglottic stenosis)
Withdraw ETT
Place suitably sized ETT (size 6-10: inner tube 6-10mm for adults) after cuff tested and lubricated
Suture cuff in place
Close skin with nylon
Tracheosotmy tape around neck

Complications
Haemorrhage (up to 40%) (3% pts have thyroidea ima artery)
Tracheoinnominate fistula if tube too low in trachea
Tracheal stenosis