Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it?

The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.

Hospital care in severe trauma: Initial strategies and life-saving surgical procedures.

Severe trauma patients should be received at the hospital by a multidisciplinary team directed by a "trauma leader" and all institutions capable of receiving such patients should be well organized. As soon as the patient is accepted for care, the entire team should be prepared so that there is no interruption in the pre-hospital chain of care. All caregivers should thoroughly understand the pre-established protocols of diagnostic and therapeutic strategies to allow optimal management of unstable trauma victims in whom hemostasis must be obtained as soon as possible to decrease the morbid consequences of post-hemorrhagic shock. In patients with acute respiratory, circulatory or neurologic distress, several surgical procedures must be performed without delay by whichever surgeon is on call. Our goal is to describe these salvage procedures including invasive approaches to the upper respiratory tract, decompressive thoracostomy, hemostatic or resuscitative thoracotomy, hemostatic laparotomy, preperitoneal pelvic packing, external pelvic fixation by a pelvi-clamp, decompressive craniotomy. All of these procedures can be performed by all practitioners but they require polyvalent skills and training beforehand.

Penetrating pelvic trauma: Initial assessment and surgical management in emergency.

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

Temporary vascular shunt for damage control of extremity vascular injury: A toolbox for trauma surgeons.

In an emergency, a general surgeon may be faced with the need to treat arterial trauma of the extremities when specialized vascular surgery is not available in their hospital setting, either because an arterial lesion was not diagnosed during pre-admission triage, or because of iatrogenic arterial injury. The need for urgent control of hemorrhage and limb ischemia may contra-indicate immediate transfer to a hospital with a specialized vascular surgery service. For a non-specialized surgeon, hemostasis and revascularization rely largely on damage control techniques and the use of temporary vascular shunts (TVS). Insertion of a TVS is indicated for vascular injuries involving the proximal portion of extremity vessels, while hemorrhage from distal arterial injuries can be treated with simple arterial ligature. Proximal and distal control of the injured vessel must be obtained, followed by proximal and distal Fogarty catheter thrombectomy and lavage with heparinized saline. The diameter of the TVS should be closely approximated to that of the artery; use of an oversized TVS may result in intimal tears. Systematic performance of decompressive fasciotomy is recommended in order to prevent compartment syndrome. In the immediate postoperative period, the need for systematic use of anticoagulant or anti-aggregant medications has not been demonstrated. The patient should be transferred to a specialized center for vascular surgery as soon as possible. The interval before definitive revascularization depends on the overall condition of the patient. The long-term limb conservation results after placement of a TVS are identical to those obtained when initial revascularization is performed.

[Long fingers articular fractures treatment by glued traction]. / Traitement des fractures articulaires des doigts longs par « traction collée décoaptante ¼ (TCD).

Comminuted articular fractures of the fingers are a real surgical challenge. Many surgical treatments are proposed, but despite their complexity, their results are often unsatisfactory. We describe a simple and functional treatment intended to ensure these articular fractures heal in the right position. The material used in this technique is inexpensive and easily available.

[Management of seat-belt aorta in severe polytrauma: a review]. / Traumatisme fermé de l'aorte abdominale chez le polytraumatisé. Comment hiérarchiser la prise en charge à la phase aiguë ?

Blunt trauma of the abdominal aorta is rare. Secondary to high-energy trauma, it is observed mainly in association with complex lesions. Evaluation of injury to the aorta must be a priority due to the risk of life-threatening massive hemorrhage. The clinical presentation can be quite obvious but also variable and often misleading. If in doubt, a systematic injected whole body scan is essential to diagnose aortic lesions. Hemorrhage or ischemia dictates emergency laparotomy. Opening the retroperitoneum increases the risk of infection if there is an associated gastrointestinal tract injury and may contraindicate use of arterial prostheses. Endovascular treatment can be proposed for less symptomatic lesions, including intimal dissection. Stents can be inserted via a femoral approach. In the event of juxtarenal dissection, there is a risk of renal artery thrombosis. Endovascular treatment is currently not recommended. This treatment can be delayed for a few days if necessary. Morbidity is low and long-term results are good.

[Is emergency revascularization of tracheo-innominate artery fistulae mandatory?]. / Faut-il revasculariser en urgence les fistules artérielles trachéo-innominées ?

Tracheo-innominate artery fistulas are a rare but life-threatening complications (incidence between 0.1 and 1 %) occurring in tracheostomy patients. Surgery is the treatment of choice. Most authors recommend ligation of the innominate artery, which provides better results in terms of morbidity/mortality than revascularization surgery. We report here a case of innominate artery revascularization isolated from the trachea by a sternocleidomastoid pediculate interposition graft. The procedure was successful as demonstrated by the 2 years follow-up. Revascularization surgery should be reserved of specific cases. The risk of tracheal-mediated infections developing in contact with the vascular sutures warrants systematic use of an interposition graft isolating the trachea from the innominate artery.

The superior epigastric artery does not pass through Larrey's space (trigonum sternocostale).

The passage of the superior epigastric artery (SEA), the terminal branch of the internal thoracic artery (ITA), through the inferior orifice of the thorax differs in different reports. According to some, it passes through Larrey's space (trigonum sternocostale), therefore through a diaphragmatic orifice, but according to others it passes in front of the diaphragm and the transverse abdominal muscle. The aim of this study was to determine the position of the SEA in its thoracoabdominal segment. We carried out a series of 14 dissections (10 on embalmed cadavers and 4 on unembalmed cadavers), and a study of images from the Visible Human Project. Dissections always led to the same conclusions. After having dissected the trigonum sternocostale, we observed that no vascular element was present in the space, which was obstructed downwards by the parietal peritoneum and limited forwards by the aponeurosis of the transverse abdominal muscle. Inferior digitations of transversus thoracis were joined with the transversus abdominis. The SEA passed in front of the plane formed by these two muscles while the sternal and costal parts of the diaphragm were behind this plane. Whatever the level of the section of the Visible Human Project, there was always a musculoaponeurotic plane between Larrey's space and the superior epigastric artery and both veins. Larrey's space, or trigonum sternocostale, was limited medially by the lateral border of the sternal part of the diaphragm, laterally by the medial border of the costal part of the diaphragm, and anteriorly by the musculoaponeurotic plane formed by the transversus thoracis above and the transversus abdominis, below without a clear boundary between those muscles. The SEA, the terminal branch of the ITA, passed in front of this musculoaponeurotic plane.

[Resuscitative transverse thoracotomy]. / Thoracotomie transverse de réanimation.

The technique of resuscitative transverse thoracotomy is for use in case of circulatory arrest in the trauma patient. This technique, performed after orotracheal intubation, is initiated by a 5th intercostal space thoracostomy in each mid-axillary line. If the circulatory arrest is not caused by a tension pneumothorax, bilateral thoracotomies in the 5th intercostal spaces with transverse transsection of the sternum is performed. Middle vertical incision of the pericardium allows the evacuation of a cardiac tamponade. This wide surgical access has proved simple to perform, even by non experienced operators. It allows digital control of a heart wound, cross-clamping of the thoracic descending aorta or of pulmonary hilum, rapid perfusion of warm fluids through the right auricle and the performance of bimanual internal cardiac massage.