Abstract
- Trauma laparotomy set
- Fixed abdominal retractor, e.g., Bookwalter
- Adequate lighting including a headlamp
- Temporary abdominal closure devices should be available, if needed
Special Surgical Instruments
Trauma laparotomy set
Fixed abdominal retractor, e.g., Bookwalter
Adequate lighting including a headlamp
Temporary abdominal closure devices should be available, if needed
Positioning
The patient should be positioned in the standard trauma position: supine with the arms abducted to 90°, and prepped from the neck to the knees.
If there is concern for rectal injury and the patient is hemodynamically stable, lithotomy position should be considered.
Incisions
A midline laparotomy incision is the standard trauma incision for abdominal exploration and allows exposure of the gastrointestinal (GI) tract.
A left thoracotomy may also be required to repair extensive gastro-esophageal junction injuries.
A right subcostal incision may be needed for exposure of the retrohepatic veins.
Stomach
Surgical Anatomy
The GE junction is the intra-abdominal portion of the esophagus and the cardia of the stomach.
The fundus of the stomach overlies the spleen. These two structures are connected by the gastrosplenic ligament, which contains the short gastric arteries.
The blood supply to the stomach is provided by the left and right gastric arteries in the lesser curvature and the left and right gastroepiploic arteries in the greater curvature.
The blood supply of fundus of the stomach is provided by the short gastric arteries, which arise from the distal splenic artery.
General Principles
Regardless of the mechanism of injury, both the anterior and posterior walls of the stomach must be completely visualized in order to exclude injury.
The posterior stomach is exposed by entering the lesser sac through the gastrocolic ligament. The stomach is retracted cephalad and the transverse colon is retracted caudally to facilitate this maneuver. After division of the gastrocolic ligament, insertion and then slow withdrawal of two wide malleable retractors into the lesser sac allows inspection of the posterior wall of the stomach and the body of the pancreas.
Most injuries to the stomach can typically be managed with primary repair, as a one- or two-layer suture repair or as a stapled wedge resection of the injury.
Gastroesophageal Junction Injuries
The gastroesophageal junction is an anatomically difficult area and its exposure may be challenging, especially in overweight patients. The exposure can be improved if the patient is placed in the reverse Trendelenburg position, a fixed retractor is placed and a good headlight is used.
The first step in exposing the gastroesophageal junction is to divide the left triangular ligament and mobilize the left lobe of the liver. The abdominal esophagus is palpated (a previously placed nasogastric tube helps identify the esophagus), and the peritoneum over the esophagus is incised. The abdominal aorta is posterior and to the left of the esophagus and the dissection should be between these two structures. A Penrose drain is placed around the esophagus for retraction. Division of the left crus of the diaphragm, at the avascular 2 0’clock position, provides additional exposure of the distal thoracic esophagus.
Most gastroesophageal junction injuries can be managed with primary repair, after debridement of any devitalized tissues. The repair should be tension-free and should be buttressed with omentum or gastric fundus wrap.
Figure 25.4
(a) Exposure of the abdominal esophagus after dissection of the overlying peritoneum.
(b) Finger dissection between the abdominal esophagus and the aorta and isolation of the esophagus.
(c) After the esophagus is circumferentially dissected at the gastroesophageal junction, a Penrose drain is positioned around it for traction.
Figure 25.5 (a, b) Division of the diaphragmatic crus at the 2 o’clock position provides additional exposure of the esophagus.
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