Abdominal Injury
Once the mainstay of trauma surgeons, the need for exploratory
laparotomy has declined significantly in recent years. FAST and high-resolution
CT have reduced the incidence of negative abdominal explorations, whereas angiographic
techniques for diagnosing and embolizing hemorrhaging vessels in the liver and spleen
have reduced the need for open procedures. Urgent celiotomy,
when necessary, will typically follow the principles of damage control.[88]
The abdomen is opened and packed tightly in all four quadrants. Systematic exploration
is then undertaken in each quadrant in turn, with time taken only for hemorrhage
control and rapid staple closure of open gastrointestinal injuries. The abdomen
is packed open at the conclusion of the procedure, a sterile drape is used to cover
exposed viscera, and the patient is moved to the ICU for completion of resuscitation.
Definitive treatment of nonlethal injuries and restoration of bowel continuity are
deferred until a second operation 24 to 48 hours later.
Anesthetic management of emergency celiotomy should follow the
principles of early resuscitation outlined earlier. Adequate intravenous access
is required, as well as continuous arterial pressure monitoring. Cell salvage devices
can be used to reduce the patient's exposure to banked blood, although reinfusion
is generally deferred if the peritoneum has been significantly contaminated by bowel
contents. A rapid infusion system is advantageous for preservation of intravascular
volume and normothermia during periods of heavy bleeding. Subsequent abdominal surgeries
will occur in hemodynamically stable patients and should not present unusual anesthetic
challenges. Subsequent reconstructive procedures can become technically difficult
as scarring and adhesions develop; the anesthesiologist should be prepared for a
long anesthetic with the potential for significant hemodynamic compromise if adequate
intravascular volume is not maintained.
