Niten Singh
General Surgeon, 31st Combat Support Hospital, Balad, Iraq, 2003–2004 Vascular Surgeon, 28th Combat Support Hospital, Baghdad, Iraq, 2006–2007
David R. King
General Surgeon, Combat Support Hospital, Baghdad, Iraq, 2008
General Surgeon, Forward Surgical Team, FOB Delta, Iraq, 2008
General Surgeon, Combat Support Hospital, Haiti, 2010
General Surgeon, Forward Surgical Team, FOB Shank, Afghanistan, 2011
Trauma Surgeon, Joint Special Operations Command, Afghanistan, 2016
BLUF (Bottom Line Up Front) Box
- 1.
Proceed directly to the operating room if there is suspected abdominal vascular trauma in an unstable patient.
- 2.
The best imaging of abdominal vascular injury is with your eyes – don’t delay laparotomy for unnecessary imaging.
- 3.
The first principle of damage control surgery is control hemorrhage – don’t worry about the bowel if the iliac artery is bleeding.
- 4.
Permissive hypotension is tolerated well and often makes arterial bleeding easier to control.
- 5.
Packing of solid organ injuries is useful; however, packing of arteries that are partially transected is often ineffective.
- 6.
Finger control of bleeding is better than packing and blind clamping.
- 7.
Do not delay vascular exposures.
- 8.
Suction is not a method of vascular control and generally has no role in emergent damage control. Use laparotomy pads for visualization.
- 9.
Preop you should be thinking about how to get proximal and distal control. Intraop you should be thinking about inflow, outflow, and what conduit to use.
Introduction
Management of major vascular bleeding in the abdomen poses significantly different challenges in the resource-limited combat environment. Deployed settings for surgical care vary widely, and the surgeon must be prepared to tackle major abdominal bleeding with few resources and no imaging. In most resource-limited, mass casualty situations, a very aggressive surgical posture must be assumed. This means rapid exploration of the abdomen for any suspicion of bleeding and avoidance of imaging whenever possible. Body cavities can be interrogated surgically (or in some cases with ultrasound) to exclude life-threatening hemorrhage, and this is often necessary when no imaging is available or when imaging is impractical due to a number of casualties.
The Basics in the ER
Sometimes forgotten in the chaos of multiple unstable patients in the ER is the basic premise that the majority of patients in a combat environment are best served in the operating room. Patients with penetrating abdominal wounds or fragmentation generally belong in the operating room. Those with blunt injuries, with a negative FAST exam, and that are conversant can be observed or imaged as needed, but certainly triaged into a pool of patients who, for the moment, do not need an operation. Patients who are hemodynamically unstable and have any form of abdominal or thoracoabdominal injuries should be taken to the operating room.
There are three major points to remember in the basic work-up of combat casualties : (1) a chest X-ray (if available) rarely takes any time and can exclude massive hemorrhage into the bilateral pleural spaces; (2) obtain a blood sample for typing and crossmatching (if fractionated blood products or fresh whole blood is available); (3) a central venous line should be placed in the jugular or subclavian vein rather than the femoral vein if abdominal vascular injury is suspected.
Resuscitation should be limited to blood and blood products and antifibrinolytics. Crystalloid use should be absolutely limited or eliminated. Resuscitative endovascular balloon occlusion of the aorta can be considered if supradiaphragmatic hemorrhage has been excluded preoperatively. In trained hands, this takes just minutes and may be lifesaving.
In the OR: Getting Started
It is often easier to drape a patient if both of their lower extremities are prepped circumferentially. It may sound cumbersome, but with the number of personnel in some combat ORs, it is not difficult. Placing two down sheets and a groin towel and wrapping both feet in towels allow easy access to both legs if greater saphenous vein is needed and can allow another team to do the harvest without crowding the abdominal team. The proximal extent of the prep should include the chest to the clavicles or the chin if thoracic wounds are present. A laparotomy sheet or two split sheets can be centered over the abdomen and cover the prepped area. If vein harvest is required from the legs or proximal control in the chest is needed, the overlying drape can be cut and the area easily accessed. The prep is very quickly performed with betadine paint alone and/or with single applicator prep. During this time, you should focus your thoughts on your plan, take a moment to collect yourself, and make sure the patient has blood products and adequate vascular access.
If you find yourself operating alone with an assistant who happens to be an 11B, prep from chin to knees and drape appropriately. You won’t be doing anything fancy.
In the OR: Injuries Encountered
Upon performing the laparotomy, any number of scenarios can occur, but most can generally be grouped into one of the following situations:
- 1.
Free blood with isolated major vascular injury (rare)
- 2.
Free blood with succus and hollow viscus injury or solid organ injury (more common)
- 3.
Retroperitoneal hematomas and no major intra-abdominal injury
- 4.
Retroperitoneal hematoma and intra-abdominal viscus injury
- 5.
Pelvic hematoma
The retroperitoneum is divided into three zones in the abdominal cavity (Fig. 11.1). Remember that the zones are all about major blood vessels, so if you see a large hematoma, you generally know what vessel(s) you are worried about. As soon as you have identified the zone of injury, your next step is to rule in or rule out an injury to the primary LARGE vessels in that zone. Zone 1 encompasses the entire central region of the retroperitoneum and is subdivided into supramesocolic and inframesocolic. This zone contains the aorta, IVC , celiac, SMA , and IMA and is in close proximity to the pancreas and duodenum. Zone 2 is the left and right portions of the retroperitoneum and contains the left and right kidneys and the renal vessels. Zone 3 is the pelvic portion of the retroperitoneum and contains the iliac and femoral vessels. The main purpose of this classification is to trigger an automatic plan based on the retroperitoneal zone that is found to have hematoma during laparotomy. Many times the hematoma will be crossing zones, but it is usually clear which zone it originates from. It is also not unheard of in combat injuries, particularly explosive mechanisms with multiple fragments, to have vascular injuries in more than one zone. A few generalities regarding hematomas encountered in the retroperitoneum are listed below.
Fig. 11.1
Zones of the retroperitoneum . Zone 1, central retroperitoneum which contains the vena cava, aorta, and their major branches. Zone 2, lateral (or renal) space which contains the renal vessels and kidneys. Zone 3, pelvis which contains the iliac artery and vein system (Modified from Cook PR, Dilley RB. The Inferior Vena Cava and Iliac Veins: Management of Operative Injuries, Obstruction, and the Palma Procedure. Operative Techniques in General Surgery 2008; 10:154–163, with permission from Elsevier)
Hematomas in Different Zones
- 1.
For blunt trauma ONLY, do not open zone 2 or 3 hematomas and retro-hepatic hematomas unless expanding or pulsatile, or patient instability with no other sources.
- 2.
OPEN and explore all penetrating hematomas except for the retro-hepatic hematoma (unless it is ruptured, pulsatile, or rapidly expanding).
- 3.
There are exceptions to these rules (discussed below), but they are unusual.
Although this is a fairly simplistic algorithm, since many of the injuries you will encounter are penetrating, you WILL explore these hematomas. Often these injuries are not going to “sneak up on you”; they will likely be filling the abdomen with blood.
The only scenario in penetrating trauma where you may want to delay opening a hematoma is in the patient with multiple injuries who is unstable. If the size and extent of the hematoma does not explain the patient’s unstable physiology, you may want to leave that hematoma alone initially and look for the hemorrhage source that is really killing the patient. These other sources could include previously quiescent extremity hemorrhage (blood loss “under the drapes”), blood loss into other cavities (such as the chest), scalp hemorrhage, or cardiac tamponade.
In the OR: Operative Technique
Most penetrating abdominal vascular injuries are noted in conjunction with hollow viscus injury. Therefore, if there is massive blood and succus or stool encountered, the initial tasks are identifying the vascular injury and controlling it with finger pressure or clamping after gaining appropriate proximal and distal control. Wide, aggressive vascular exposures should be the norm.
Zone 1 Supramesocolic Injuries
If a zone 1 supramesocolic injury or hematoma is encountered, a left medial visceral rotation should be performed (Mattox Maneuver) (Fig. 11.2). This maneuver allows visualization of the entire abdominal aorta from the hiatus to the bifurcation. The exposure involves mobilization of the left colon, dividing the lienosplenic ligament, and bluntly elevating the left colon, left kidney (optional), pancreas, and stomach. Once the peritoneum along the line of Toldt is opened, the rest of this maneuver can be rapidly done with blunt hand dissection and bovie. Sweep everything medially until you feel the vertebral bodies. Once the viscera are all rotated up off the retroperitoneum, there is usually a thin plane of tissue along the side of the aorta which must be opened to directly expose aortic adventitia and aortic branches. If there is active bleeding from this area when entering the abdomen or opening a hematoma, the aorta can be blindly compressed by your assistant at the aortic hiatus with a hand or the blunt end of a large retractor. To apply a supraceliac cross-clamp, the gastrohepatic ligament is divided, the left crus of the diaphragm is bluntly dissected, and the aorta is identified at the hiatus (Fig. 11.3). A key point is it is easier to identify the aorta if the esophagus has an NGT in it, and often it is not easy to clamp this area, particularly in obese patients. If you are uncomfortable with this vascular control technique, then an anterolateral thoracotomy is still an option to obtain proximal control. Always remember to reposition the clamp to a lower position when feasible if a supraceliac cross-clamp is in place to limit visceral ischemic time.
