TOP KNIFE - Mattox e Hirshberg

Prévia do material em texto

t'-
I||P IIE
IIIT ART & GRA]I ||T IRAUTIIA SURGTRY
Asher Hirshberg MD
&
Kenneth L. Mattox MD
Edited by Maty K. Allen
Illustrated by Scott Weldon
TOP KNIFE The Ad a C of l ofTrolmo slrgery
Cover design:
lJm Pub shing Ltd, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX, UK.
Telr +44 (0)1952 510061i Fax: +44 (0)1952 510192
E-ma i nikki@lfnrpubl ishing.com; Web s ie: www.i fmpubl ishing.com
Ediior: lMary K Allen
Design and ayout: Nikk Bramh l l
lllstrations by Scoti Weldon, Copyrighi O Bayor College of Med cine 2005
Copyight O January 2005, Asher H rshberg MD & Kenneth L Mattox MD
Repr nted Apri 2005, October 2006
lsBN 1 903378 22 2
Apad ironr any fair dea ing for the purposes of research or private study,
or crtcsrn or review, as permlt ted under the Copyright, Designs and
Paients Acl 1988, this publcaton rnay not be reproduced, stored n a
retneva sysiem or irarsmitted n any forrn or by any means, eectronic,
digi ia l , mechanica, photocopyng, recording or othelwise, withol t the
prior written permiss on of the publisher.
NOTICE
Ne iher the authors, nor lhe pub isher, nor any other party who has been
invoved in lhe preparai ion or publ icat ion of this work can accept
responsibilty for any injury or damage to persons or property occasioned
through ihe mp ementation ol any ideas or use of any product described
herein, Neiiher can they accepl any respons br iiy for errors, or.iss ons or
msrepresentatrons, howsoever caused,
Whilst every care is taken by the authors, the ed tors and the p!b isher to
ensure that all informatiof and data in ths book are as accurate as
possib e ai ihe time of going io press, il is recommended thai readers seek
independeni verJcat on of advice on drug or oihef product usage, surgical
racl_n qJes .r d c i rKa p.ocess6c pr or to r ' rei . Jsa.
!
pqge
I
E
7L
99
19
35
Contents
Introduction
What this Book is all About
SEcrloN I - Tools oF THE TRADE
Chapter l
r The 3-D Trauma Surgeon
Chapter 2
Stop That Bleeding!
i ct'upte' e
I Youi Vascular Toolkit
I
i SEcrIoN II - THE ABDoMEN
Chapter 4
The Cxash Lapalotomy
Chapter 5
Fixing Tubes: The Hollow Organs
Chapter 6
The Injured Liver Ninja Masier
Chapter 7
The ' Take-outable" Solid Organs
53
TOP KNIFE The Ar1 & Croft of Troumo Suroerv
Chapter 8
The Wounded Surgical Soul
Chapter 9
Big Red & Big Blue: Abdominal Vascular Tmuma
SEcrroN III - THE CHESr
Chapter 10
Dorble Jeopardy: Thoracoabdominal Injudes
Chaptff 11
The No-nonsense Trauma Thoracotomy
Chapter 12
The Chesr Inside and Out
Chapter 13
Thoracic Vascular Tmuma for the General Surgeon
SEcrIoN IV - THE NECK AND ExrREMrrrEs
Chapter 14
The Neck: SaJad in Tiger Counhy
Chapter lS
Peripheral Vascular Trauma Made Simpl€
Epilogue
The Joy of Trauma Suigery
pase
115
131
147
157
17L
181
't99
215
233
Contributors
Authors
Asher Hirshberg MD FACS, is Professor in the Depariment 
o{ Surgery'
iut" o.*n",*" college of N/edicine and Director 
of Emergency
i"'""rtu!' Srrg"ry 
"t 
Xings County Hospiial Cenier in Bfooklyn' New York
Kenneth L. Manox N4D FACS, is Prolessor and Vice Chair 
of the Michael
i. o"ir*t Deparir.ent of surgery, Baylor college o{ 
Medicine' and
Cn[i 
"t 
si"olin*t of Surgery at the Ben Taub General Hospltal'
lllustletot
Scott Weldon N,4A, is Supervisor Medical lllusirator in the 
Division o{
Cardiothoracic surgery of the Michael E DeBakey Department 
ol
Surgery, Baylor College of lvledicine, Houston' Texas'
Editot
Mary K. Allen BA, is Administrative Associate in ihe Michael 
E DeBakey
o"p"ri-"nt ot srrg.ry, Baylor College o{ N4edicine' and Administrator 
of
the Surgery Divisio; al ihe Ben Taub General Hospital' Houslon' 
Texas
To our residents -
past, present and future
Introduction
What this Book is all About
When you hatte to shoot - shoot' dofl't talk
- I1i Wallach (Tuco)
in: The Gaotl' the Bad and lhe U+l! ' 19136
Sooner or later, I haPPens'
You are a young aitending surgeon doing your first 
night on call at a
ur"u tt""t" 
""*o 
ol. 
" "rig"on 
in a community hospltal facing a bad
traLr'ma case alone and wiihout backup Pefhaps you are a miliiafy 
surgeon
witn a forwarO or fietO Surgical Team sooner or later' 
you Jind yourseli
in tt e operating -om 1OR) ;ith a massively bleeding 
patieni rapidly dyrng
YoJ o|.icklv open ll^F beJy and blood gushes out LooD" o{ 
bowe are
"*^. ' ln 
i - ' ' " p.a 
" f 
a"rr btood a'd c 'oLs Hect ic act iv iy sJrroJrds voL
as the aneslhesiology ieam struggEs ro open more 
lines while ihe
;;";",'"; ,.." rursJ" rapidlv oeprov 'nsrLmeri rrav5 
YoL don\ need Io
,J* l , in" 
"n-"n 
nrmbei, or r t te -ontor to leal i re I l "aI lhrs 's rhe
Moment. The skills that you have worked so hard to acquire 
are suddenly
pui to a very bruial test Can you meet the challenge?
These cases almost invafiably roll ihrough the emergency 
room (ER)
aoor" *h"n vo, t""t yo, are not at your best You are tired 
and tunning on
"rr l i i " . t 
u" i" t i "" Your sc,ub nu'"e is 
'not very experienced' The
""""tf 
i"i.f"g 
"t" 
afe doing lheir besi by pushing bolus after bolus of a
;;;;;;" ";"" 
iror'ooic-asenl rne crrcu'|arils nJ se d s'ppeared o'I
in" r" l r t * t""" t"" - ' "utes igoin searcr 'o 'your 
lavori le vascJlar clamo
Yes, this is deflnltely not a good iime, bul we can assure 
you' it never is
Tie audlble bleeding in tho belly, the controlled chaos 
around yo!' the
iii"n*n *a ,'ght" ii your head, and the clLreless assistant 
across the
TOP KNIFE The Ad & Croft of Troumo Surgery
operaling tab e are all pad of real-life trauma surgery. Oh, and by the way,
have you noticed the anorexic chap in the black robe and hood, standing
in the corner of the OR, holding this big scythe, and patienty wailirg for
you io make lusl one mistake? He, too, s an iniegral part of lrauma
surgery.
Traurna surgery is an art ihat combines decision-making wth technica
and leadershlp skllls. The purpose of this book is io help you take a badly
wounded patient to the OR, organ ze yourself and your team, do battle
with some vicious injuries, and come out wiih a live patieni and the best
possible result. The siardard surgical atlas may show you whal to do wrth
youf hands bul not how to ihink, plan, and improvise. This book is
different. Here you wlllfind practrcal advice on how to use your head as
wel as your hands when you are operat ng on a cfashing trauma patient.
Who should read this book? Afe you a resldeni or registrar in the sen or
years of slrgical traning? A general surgeon iniefested ln trauma? A
felow ln traurna and crrtcal care? lf you are, we wrote this book primarily
wi lh you in m nd.
lf you are cufrently in lfaining, you must be aware oI ihe strong forces
dramai ical ly feducing your operat ive trauma experience. lJrban
penetraiing irauma is dec ining, non'operatrve r.anagement is on the rise,
and surgica train ng is undergoing a noisy revo uUon. Whle this book
cannot substitlte for gelting your clogs wet in a real OR, i can opt r.ize
ihe educationa value of every Aauma operation you do because you wii
lvlany operative encounters with bad inluries iake place in austere
cifcumsiances, The rura surgeon doing an occasonal major yauma case
alone, the miitary surgeon in the f eld, and ihe disasief relief ieam on a
humanitarian mission are examples of irauma surgery wilh extremely
I mited resources. Tackling a high-grade liver i.jury n a large irauma center
is bad enough. Do ng it n the only OR o{ a 20-bed hospila iakes tons of
courage and resourceJu ness. li you afe ore of ihose surgeons, you are
probably more nteresied in slmple techncal solulions that work, raiher
than complex maneuvers that you wonii use aryway, Most operatve
problerns in trauma have more than one effeciive answer, and the trick ls
lntroduct lon w,o ih Boor B or "" . , E
lo tailor a simple, feasible soluiion to your speclfic circunrstances. In this
book, we show you how to do jusi ihat.
Ths brings us to damage control, the biggesi buzzword in trauma
surgeryin the lasi decade. You rnay wonder why you don't see a chapter
on damage control in the book. The answer rs simple. Damage control has
become such a centfal theme in trauma surgery thal it no longer makes
sense lo confine it to a single chapler Instead, detaied descriptions of
damage control options and lechnlques are part oJ every chapter. Thinking
of ihis book as a comprehensive guide io damage control would noi be a
Why Top Knife? Top Gun is the popular name of the Naval Fighters
Weapons School. The r mission is io train the very besi fighter pilots for
ihe US Navy. We called our baok Tap Knife )n recognition of the many
simrlarities between trauma surgeons and frghter pilots: clear thifking
under pressure, responding effectively lo rapidly changing stuatons, and
a ong and arduous training process. Just like aerial combai, iralma
surgery is, f rst and foremost, a discipl ne. You cannot become a frghier
piot or trauma surgeon without a lot of hard work and willingness to face
The book begins and ends in lhe OR. lf you are looking for information
o n care of ihe njured patient beJore or after ihe ope ration, look e sewhe re.
We also assume that yo! are famillar with general surgical princ p es and
lec hn iq ues. lf yo u seek nstruclion on how to reseci and loin bowel or h ow
to do a standard vascular anastomosis, you w ll not find lt here. However,
if you wish io learn how io do a no-nonsense crash laparoiomy, deal with
a bleed ng Lung, or repair an injured popliteal ariefy, read on.
The f rst seciion of the book, Toals of the Trade, presents princlples of
irauma surgery that cll across injury types and afatomical areas. Our
focls s not so much on how you should be sewing, but rather on how you
should be thinking and reactlng. These skills are rarey if ever talght ln
surgical irainlng. lf anyone ever showed yo! how io develop an alternative
plan whlle struggling wilh a bleeding subcavlan artery or to pay aiteniion
to what the circulating nurse s do ng while you are manualy compress ng
a shattered liver, consider yourself very fortunaie. IVost surgical residenls
ToP KNIFE The Art & Croli of Troumo Surgery
and regislrars are expecled to just inluiiively 
piok up those skills
somewhere along ihe way Many never do'
The resi of the book is about trauma surgery as 
a conlact sport Here
*"'"i".* t"" n",r a o""lwith speci{ic 
injuries An impodant lheme is how
it',ino" 
"un 
go 
"rong, 
an aspect of trauma surgery seldom addressed 
in
:i,"L;J ;J; t;";.onaiize pitralls because recosnizins 
them is an
essential part of learning 10 operale
We acknowledge that the ari and craft o{ trauma 
surgery vary among
"";""";.';;"'il;",'prised 
lo find some differences in the approaches
r^, i . '^r^rrue orob'e-s between Ine auLnors Tl"e unoerly inq 
or lrLlplFs are
;":;;; il 
""r-n'q,"" 
''" 
"o'"t'""s 
d qere'.r' wl'ere such vaf:alio'rs
exlt, we have pointed them oLll No one size fits 
all'
In developing this book we had ihe good fortune to 
pariner wiih Scott
w"faon, 
"n'""ti"otain"tily 
gifted young medical illustraior' The iranslatron
. i .*" t" , ,a"". 
"no.o*"ot* 
nto qrapnrcar tot- 's alwavs a t ' (v
"""i."""t. 
ff'..1't to Scoii " taent 
and sLperb i,rlurtror' we we'e able lo
""fr""" 
tni" author_artist parinership as a single voice that 
seamlessly
interweaves text and an.
lvlarv AlFn, t\e most larenlpd Fdtor we l^ave ever worked 
wth did
,oln" ,'uoi"o ruro",y ot lne ipn ano mercrlessly bear h ilLo 
sl'aoe unt.l st'e
g";ii!", tiglt. Wih'*, t'er remarkable e{forts' this book would 
have been
much longer _ and considerably less readaEle'
Nikki Bramhlll, our publisher, was a lull padicipanl in this 
proieci {rom
rhe embrvolic sLages 10 lhe ii'rar prodLct She bougll 
'nto our idea to
*r i t" 
"" 
' j t t . " ; l : "" *""1 op"ral 've book or rraLma surgery and 
wo' led
;';;;" ;;"t step o{ the wav io make it happen 
Her infeciious
enihusiasm, h;rd work' and superb eye are evidenl on 
every page'
And now, ii s iime to stop talking 
- and start cutting
Chapter 1
The 3-D Trauma Surgeon
An erpett is a man who has made all
possible mistakes i a oery naftow fielil
- Neils Bohr
The flrst thing you notice on enlering lhe peritoneal cavily is bleeding
from a arge nasty hole jn the right lobe of ihe llver Sirange y enough, you
were in exacty lhe same siiuaiion a week ago You don'i even have to
glance at the monitor lo know the syslolic pressure is go ng to be 60
Remembering last week's case, you rapidly pack ihe liver to stop the
beeding. Howeler, this i ime the injured vet cont inues io beed through
the packs. lt was supposed to stop. lt did last week. What's wrong?
Whai's different? You do a Pringle maneuver, but it doesn t help much-
The rietalllc voice of the anesthesiologist alerts you that the patreni's
systoic pressure ls now unobtainable. He s dying What s gong on?
What do you do now?
You rerialn surprisingly calm for a sutgica resident with ony three of
four years of training. The reason is simple: you know exactly whai comes
nexi. Soon the l ights n the Surgical VrtuaL Real i ty Labwil l be turned on
and ihe simllation wil pause. Using a revolving hoogram of lhe injuted
Liver and retrohepatic veins, your instructor wil explain what went wrong
and why. This dry clogs' approach to teachlng surgety ls rapidly
becoming a major part of surgical itaining. A simulator can helP yo! learn
10 operale, yel somerhrng l . r_dame' lra is aissi 'g
When you work on a simulator, operaie in a large animal lab, or work in
the OR with a good ieaching assistant, you learn ihe taclica dimension of
the operaiion. You learn to select from several technical optlons ard
execute your choice ln specific operative circumstances- You spend mosl
of your surgical training focused on operative tactcs in elective and
emergency procedures. Only when you begin operatlng on your own do
you become aware of the olher two dirnensions of every operation:
sirategy and team leadershiP.
TOP KNIFE lhe Arl & Crofi ol lroumo 
Slrgerv
The shategic dimension
oJ an oPeraiion is ihe
broad considerat ion ol
goals, means, and
alternat ives. When You
operale with a teachrng
assistant, Your teacher
usual ly handles ihe
strategic dimension lor
you. Whi le You are
absorbed in mobllizing the
spl€nlc t lexure, Your
ieacher is already
weighing the options of a
rapid damage control
laparotomy against a time-
consumino definrtive repair. when you are working on 
your own' tne
",r.*i" 
"ait"""io" suddenly falls on your shouldefs You can no longer
io"r"""*"tr"iu"tv on d," fole; ln the colon, but must also considerthe 
'Big
The ihird dimension of every operation ls team leadetship 
Being a
surqeon means making sure that ihe etforis o{ the OR ieam 
members are
coordinated and {ocused on ihe same goals You cannoi assume 
yoLlr
"irui 
t""t' lno*" tt'"t to do next lust because he or she is 
smari and
experienced. You must clearly communicale your 
pLan Similarly' the
anesthesiologist does not have extrasensory percepiion and 
cannot guess
your plan uniess you share i t - Mishandl ing ihe team dlmension dunng 
a
iuuma op"ration is one of the worsi mlstakes you can make
To operate effectively on wounded paiients' you musi train 
yourself to
be a 3-dimensional surgeon who consianily zooms in and 
out ot the
lactical, strategic, and team dirnensions' nronlioring Progress 
ano
reassessing options in each
I The 3 D Troumo slrgeon
Putting brain in gear before knife in motion
Srraleqic lnrnk;ng is essential even oe{ore 
yo!' make the 'ncslon
;;^d;: ;,'";"-pi",he brack no'e', oJ,sLrse'[ l;'fitiii,"J:.;"f:
::i:'",'::il:::,H""6J #,'-Jl-il:ii J"" r,s an obrisatorv,os;st'|c
[1; ; ; ; : : ; ; ; ; ' ; r ' "" p. . ,ent 
is 'novFd oosir ioned ano preoa-ed but
nothing is done 10 stop inlernal bleedrng
l{ vou choose to spend most of the black hole 
iniewal at ihe scrub srnK'
*" i'"" 
""i 
* -*t;;an fingernalls, but when 
you enter the oR vou will
i; ;;;;;';;"""'tv oosiiionedLl'e scrub 
nLrse prepo'ns Ihp wrong
i,"rl. 
""1 
,t'" on,"". 
"nort 
in disartay You aray welr haverosl'ne battle
#;; ; ; ; ; ; " . . ; ro avoidt l ' ' |s srav wrth vour 
oat ienl unl" the'asl
o"i"ii'" .iit*t -a *e InP olack hore 
lor e'ective p'eoaratiols
ls the patient positioned properly? Does the OR 
ieam know which
"""]"1"" 
;J ; ;;;;" ,ni *n''r''""t"'".' "ers 
to deorov? Does rhe
;;;;"'. -"". need he p wilr^ rres? You ca'not 
address these
ir!ii'.#r",n ir''" ""',u "ink 
Go ana s"rub onlv when vou are sure that
everyihing is set uP ano reaoy'
lf the patieni is in shock, don't waste.time on scrubbing 
Every second
"orni". 
j*, g" u go"n und gloves' grab a knife' and rapidly dive into 
the
chesi or abdomen.
Sterility is a luxury in severe hemorrhagic shock
The way You Posiiion the
patient and define the operatlve
lield are other indicatorc of }/our
sirategic vision. Always Pfepare
lof a worst_case scenario' In
iorso irauma, this typically
involves access lo both sides o{
the diaphragm and to the
grolns, Your worst_case
operative field extends from ihe
chin to above the knees'
IOP KNIFE lhe Art & Croli of Troumo Suroerv
between the posterior axtllary lines. Abduct both arms to allow the
anesthesrology team full access to the upper extremities.
For isolated extremity trauma, include the entire niured extreriily in the
field to facilitate rnanipulation, and prepare an uniniured lower extremity {or
saphenous vein harvesting. For a neck exploration, pfepare ihe entire
chest, since the uoDer mediastinum is a coniinuation of ihe neck.
Always prep for a worst-case scenario
ABC of tactical thinking
Traif yourself to ihink of every operatlon as a sequence of well-def ned
steps, but menrorizing the steps is not enough. You must ga n insight into
the procedure by earning the key maneuver and the piiJall in every step.
A key maneuver is the single most important technical act in an
operative step. The key maneuver in mobjlizing an injured spleen is incis ng
the splenorenal lgament and entering the correct plane beiwean ihe
spleen and the krdney. Often, a key maneuver is identlfying a gatekeeper,
a siructure ihat serves as a guide to dissection or opens the cofrect iiss!e
plane. The galekeeper ofthe carotid artery in the neck is the common facia
vein. ldentfying and dviding it is the key maneuver. When mobi zing the
hepatic flexure of the colon, the key maneuver is finding ihe plane between
the rlght side of the transverse colon and the duodenum.
A p/tfal/ is a major trap that awalts you in every operative step. Choos ng
an incorrect ihoracoiomy incision or perfoming it ai ihe wfong inlercostal
space is a major pitfalj. Fail!re to obtain proximal control be{ore plunging
into a contained hemaioma is another classc trap,
Fam liarity with both the key r.aneuver and classic pitfall of every
operat ve step s the d ifference between the trau ma p ro and th e wannabe.
Knowing the key maneuvers and pitfalls ofa procedure allowsyou to pei{orm
the procedure lndependently and, with experience, teach lt io others.
Know the key maneuver and pitfall in every operative step
t rhe 3-D rro,rmo surseon I
A common tactical dilemma
"l:";f :;:1::ilil1',::ilT 
jlilH;"i""ji;ft ::::"H;Fti
iK,f ily:Jt"f ?:r,ff Tiit"i,l,"?:Jl[:":'ff 1['ili::^-H]l
oJ"""i t-i 
-t"" 
ut 
"naini 
maybe it will wo* this time We can tell 
you
:il;:*[:lmig ii: :t'*"ll]; rl::: lxH"lff :;:lJ il"'
Get used io lr"e ided that n,Ihe nt ::"",liJli"i"TJJ::1"::":::j
"*"'"-'";'ill'liJl"i,liiil;'i] Ll'l"""'" ;'| 'ai'| -re'rrect ve'|v no'l
" ."* i" ' ' , 
*n"" a maneLver ooesr t wori don t i€ke:t 
as a oersondl
failure. Pause and consider your optlons'
First, reconsidef the need {orthe
lailed ac1. ls it really necessary?
Does ihe bleeder require a sulure?
Perhaps it will stop wlth iemporary
pressure and Patience'
Another oPtion is to retreat and
gei help lt You are iortunate
enough to have backup' use lI'
Someone more experienced oiten
has a better chance of solving the
problem, Recognizing the need lor
irelp and asking for ii (whether you
are a resident or seasoned trauma
surgeon), is a sign of good
ludgmenl
what ir you are compreierv ":1111:Y: *i"J,?:;J;til;,:::lilT:
l::'[f]''T#'.""''fl5'$li]:"i"."iJ::1ff l'"" "st come up 
wirh one
ihai will.
,'"Hl"i::"i:Xff ,i:ili, tii,'i5;Jlliiiill ll'iil"Jff T:['""5i
getreaf
.f"
c a
o
t.
TOP KNIFE The Ari a Crof i of Troumo Surgery
envrronment: lletter exposure, an improved angle, a longer needle drrver,
a bigger needle, or a better asslstant. Such a taciical change improves
your chance to succeed in ihe next aitempi. tdentjcat repetition of an
unsuccessful iechnical act is a nristake because ii almost always fails. Thrs
is lhe very deflnition of flailing and exactly whai you must avoid.
Remember these four options for dealing wlth technical failure. They are
your iickets oui offrustraUng and dangerous situations. Effectjve surqeofs
don I take lech'r ,cat ta lLre as a persora .nsrt t . Tt-ey .ap dly reasse;s the
siluation and come up with an alternative solltion.
Avoid f lai l ing; learn to dealwith technicalfai lufe
a
Tactical flexibility
Regafdless ofyour experience, you willfi/rd yourseif in sttuatrons where
your inventory of slandard techniques simply will not solve the problem,
forcing you to figure out a new solution. Tactlcal flexibility js the ability to
devise new solutions to unusual operative situations. lt is an acquired sklll
that you can develop by learning to think outside ihe box.
When facing an unfamil iar problenr, ask yourselJ the fol lowing
Have lencouniered a srmi lar st tuat ion in another context? ln electve
surgery? In another injured organ or anatomical region?
Can I modify or adapi a standard technique to the situation?
How about solving part of the problem?
Can I leave the prob em unsolved {or a while and come back later?
Whai is lhe mininral accepiable option to deatwtth the probtem? Witl
draining the niury (and creaiing a conifolled fisru a) be good enough?
Can I hgate the vessel lnstead of repairifg it?
In a complex situation, always strlve to simpllfy the problem. Assess ihe
iniufres and decide which injured organs must be fixed and which can be
rapidly removed (or fesected) and, thus, etiminaied from the equation.
a
a
a
a
Make your reconstructions as simple as
yoLr rnake, the better. ln trauma surgery'
solulions often backfire on You
1 The 3-D Troumo sureeon I
possible. The fewer suture lrnes
simple solutions worKi compLex
The key stratedc decision
Every trauma operation follows a generic sequence 
of reproducible
o"-0". i", g;t 
""""*,o 
the injured cavity' control bleeding and spillage
;#; t;;;;;,y '"""u,.", "ni 
then explore ihe cavitv to define the
K" \..t11- a
// 
" "*' 
+\9 ot;*a//,// " t! \
/ 7 / F ' i ' \ !
Acc€$ and TempoEry Bleedlng ErploEtion
Expo.ur€ conlrol
Now voJ lace tl'e kev strategic oecison ol tl'e ope-aiion 
ll'e cro'ce
o"*""" a"ti'ni"" 'epai' ana Ja-ag" control Dernd^e 
rcpai mears
Lection or reparr of the injured organs and 
{omal closure oJ ihe cavity''Fti',i 
""ri,[,."i.",^pij 
bail out u"ing temporary control measures and
l-""i"* U""rr" ol Ihe cav;ty. will' a planned relur' 'ater 
under mo'F
,,;;;;"'";;"";""-. vo, 
ju"r -at'" it' 
" 
d""'s'on vFrv earv Don\ { 1d
yoursel{ abruptly bailing out in mid'operation becauseihe 
pai|enl rs crasnlng
How do You choose the operative profile? Consider 
fouf key Jaciors:
iniurv oaiter;, rauma br.rrden, physiology' and system
a What is ihe injury Pattern?
For example, in a high-grade liver inlury'
Simplity complex tactical situations
d h
once you recognize the need
a
a
TOP KNIFE ]he Ad & Croit of Troumo Surgery
for packng, damage control is your only choice. Simiar ly, the
combination of a major abdominal vascuJar injury and intesiinal
perforalions usually requires a rap d bail out, because by the time you
finish dealing with the injured iliac artery, the patient wil be n no
condition to undergo bowelresection and anasiomosis,
What is the paiient's overall ifauma burden?
Look nto the njured bellyt how many organs do you need to lix? How
r.uch work is involved? What aboutthe chest? Any press ng concerns
in the Imbs? The pateft may need two hours of reconstructive work,
blt with a head injury and a diaied righi p!p I, you don'i have the iime.
The overal trauma burde. oi a pailent s a combination of the njuries,
iheir relative urgency, and the amount of work (and time) required to
deal wiih ihem. Investing precious irme in definitive repair of nonl/fe
ihreaiening abdominal injuries n the presence oJ big uncenainties in
ihe head, chesi, or neck is a very bad move.
Whai is the patient s physiology?
The numbers you see on ihe anesthesiologist s monitor are noi very
he piul because you are not interested in a snapshol of ihe patient's
blood pressure or oxygen saturation. You are ifierested in ihe
physiolog calimpact of ihe njury overtime. The instanianeous numbers
you see on the monitof mean very ittLe. lvlore on th s n ihe next seciion.
What system and clrcumstances are in play?
Are you an experienced trauma surgeon working n a trauma center
or a generalsurgeon operaiing in a tent in Africa? How mlch biood
do you have? How good is your anesthesiologist? You musi
incorporate ihese considerations into your decision. Damage conifol
is the 'greai eq!a izer" o{ tfauma surgery, alow ng you to compensaie
for nexperence and lmited resources.
Damage control is the great equalizer of trauma surgery
The decision to bail out and the physiological envelope
ll the patieri s cLrnent blood pressure is 120/70 wiih good oxygen
saturation, the anesthesiologist wil often tell you the patieni is stable.
What if this patlent was n shock for an hour before ihe operation and lost
an entire blood volume before you gained conirol? Are you going to do a
a
r The 3-D rroumo surseon n
bowel resection and anastomosis? lf 
you answer' 'Yes" please say you
:rinrijffi :r";'; * :i ;* *:6116';F#
l,1i#lll,J""''-,"?l;,1':#T" "# "T ;'"""," m;ss ve r'|J'o
:r"L",":*:*1,*n::i:'::::"ffi i,Bff iJil'iJ""":*iii:lil:
Ir*ri"il" ont"i""n'""1 insult, not the numbers on the 
monitof screen'
should guide Your decision
ln the damage control
l i teraiure thefe is much
discussion o{ the 
' lethal
tr iad" of hYPothermia,
coagulopath)/, and acrdosrs
These three Ph]/siological
derangements mafk the
boundaries of the Patlenl s
physiological envelope'
beyond which there is
irreversibLe shock and
death. A core temPeralure
below 32'C during a
trauma laparotomy is
considered universallY latal
Unfor iunately, in real- l i ie
;;;;;;,0;;t ihe leihal t ad does noi help vou much 
lf vou have a
;;;"i;";i srasp of the situation' votr 
will bail out well before the
p"o"nt'" pf'V"i"f.gi."f envelope is anywhere near the 
point ol no relum
Beino {orcei out o{ the chest by a core temperaiure o{ 33"C' 
a pH of 6 9'
""J 
I J"**"," anesthesiologist is not a sign of 
good judgmenl You
should have been out of that chest long ago
Don't use the lethaltriad as a guide to bailing out
TOP KNIFE The Ad & Crofl of Troumo SL,rgery
Instead of the lethal triadj re y on a seres of subile perceptua cues to
rndicaie a developing hostie physlology.
Intraoperative Cues of Hostile Physiology
Edema of the bowel nrucosa
L/idgut distension
Dusky serosal sudaces
Tissues cold io the touch
Non compliant swollen abdominal walJ
D ffuse oozing from surgical incisions
Edema and distension of the smal l bow€ are relatrvey early warning
signs, whereas diffuse oozing from the operaiive incision s a late one.
Experenced irauma surgeons decide on damage controlwth n minl tes
of eniering the abdomen and sometimes even before making ihe incisionl
They often recognze a paltern of iijury and physology thai, in their
experience, amost always eads to darnage contro. N4ore on this n ihe
chapter on thoracoabdominal injuries.
How well does youl solution fail?
lfyou choose an operative prof le of definitive repair, there s usualy
more than ofe repair option. The iypica dilenrma s beiween a shorter,
simpler repair and a complex and more tme-consurning reconsiructon,
When choosing between several technical solutions, consider not only
howwel a padicu ar optiof works but, more importaftly, how well ii fals.
Whal w ll happen if the anasiomosis leaks? Whai f the repa red spleen
begins to bleed again?
There is a world of difierence between a leakrng colonic suture ine and
a fa led pancreaticojejunoslomy. The former is eas ly salvaged by proxima
drverson; ihe lat ter is a much more orninous compl icaion, not easy io
manage. Can your patient tolerate a failure? A young healthy patient wlth
I The 3 D Trourno Slrgeon
an rsolated bowel rniLlry will suruve a
surure line A criiicallv injured patieni ln
leak {rom a gasiroiniestinal (Gl)
mulii-ofgan failure will not'
Choose a definitive repair option that fails well
Team leadershiP
Picture yourself going headlo'head wiih an inaccessible hole 
in an iliac
"" ' " ""* '4"*", i 
t lJ peru:" Your oal ier ' s n ororouno sl 'ock and
blFeoinq aLd o'y. YoLr ieam has ore c rcu alng lurse DepFnd'ng 
o'r yoJr
n" ' , i , "0"""t . ,a" . rr-" * i l e i lh€r go nJ'r , i "g lor your pe'solal ized 
needle
ariuer ttrat ttas ihe ideal angle {or your next 2_3 bites' bring 
a Fogarty
iattoon catleter itrat can free yourfinger from compressing 
ihe bleeder' or
; ; , ; - ; - ' a-.olr€1s{usio- 'devce whcn is more impolant? 
ore
lir""t"tor, ,r'r"" 
".."niiul 
p:eces o equrp'ne,rI needeo ar t'r. same Iime 
_
it s your call
Constantly re_evaluate your priorities and your team' adapt 
to the
situation, and make comprornises' lt is often said thal excellent 
surgeons
i""" .oo*" wiih a knife and fork' ls the special clamp you requested
real lv essent ia? Ca'r you gel by wirn a 'ess opi imar bJr 
_nedralely
""lii"oi" "r".p" 
wn"t *ill vor neeo ir live mi'utes? lr 
+en mi,lL'es?
The kev to a smooth and welfcoordinated operalion is to siay ahead 
ol
t fe oam"les a rut" , t t " 
scrub nurse should be at least one step ahead ol
ii" ""0"*i"" at any given mor'ent When you are exposing 
an lnjured
ue""eL, the 
".rrb 
nu."" musi already have clamps for pfoximal and disial
"oni.i. 
ff't" 
"it"ufutlng 
nurse must be at least lwo steps ahead' riaking
"rr" 
if1" ,n" Fogady Lalloon calheter and the suiures you will 
need fot
*r"*""a.t 
"ia 
,"pul, 
"r" 
ready You, ihe surgeon' must be at least
three steps ;head, considering your reconstrLrctive options 
Just as in
ci"ss, tne bette, play"r you are, the further ahead of the operation 
you wrl!
stay.
Stay well ahead of the operation
IOP KNItE The Art & Crolt of Troumo Surgery
Maintain a continuous dialogue with the anesihesiology ieam across ihe
drape they call 'ihe biood-brain bafrier," and provide them wiih the
iffornration ihey need to stay ahead of the operation. Remember that you
are working in one of several potentially injured caviiies, and often the only
clue that something is amiss in another visceral compartment will be
obvious only to the anesthesio ogist. Train yourselJ io listen to the monitor
whi le you are working and to pick up any unusual moves or noises on the
other side of the blood-brain barrier. Sometrmes the nrost criiical part of
the operation is tak ng p ace there, oulside your field of vision. While you
cannoi see tj you can train yoLrrcelf to leel ii.
Frequent changes in the operaiive plan are a salient feature of surgery
for trauma, and it is your responsibility to make sure ihat members of ihe
OR team aro noi left behlnd when the operative plan suddenly changes-
Avoid surprises by sharing your tactical and strategic decisions with them.
Consider, Jor example, the simple act of transporting a damage control
patient to the surgical irienslve care unit (SICU). lf the team is unaware of
your intention to bail out well in advance, you will find yourself in the
ridiculols situation of having just performed a lightening-speed damage
contfol laparotomy,only to spend ar almost equal amounl of time waiiing
Unike chess, trauma surgery is a dynamrc process. lr chess, the
pleces are just silt ng there, waiting for you lo make a move. A trauma
operation moves forward relentlessly whetheryou like it or not, confionting
you with rapid y changing situations. lf you are an effeciive 3-D surgeon,
your handling of the tactical, sirateglc, and ieamwork dimensions
translates into a smooih and etfective procedure.
T H E K E Y P O I N T S
Sterilily is a luxury in severe hemorrhagic shock.
Always prep for a worst-case scenario.
Know the key rnafeuver and piifall in every operative siep.)
I
) Avoid flailing; learn to deal with technical 
failure
) SimPlify comPlex tactical situations'
> Damag€ control is the "great equ€lizer" 
of fauma surgery
) Don't use the "lethal triad' qs a guide to bailing 
out'
> Choose a definitive repair option that'fails 
well'
) Stay well ahead of the operalion
r The 3-D Trcumo strrgeon I
[ ,o, *",rr rn. on & crofl of Trourno )urgery
Chapter 2
Stop That Bleeding!
Whenezet yot encotnter fiassioe bleeding' the
first thixgio temembet is: it's 
not y91!r blood
Raphael Adar, MD, FACS
In 1989, while discussing a paper on liver injuries' Dr' Francis 
Carter
Nance ol New Orleans made the following comment:
"l wauld like to offer Nance's ctassification of injuries' which has 
the
advantaoe of not needing to laok at the oryan injured' but at 
the resident
who is ;here at the operating table lf he ar she looks at lhe waund 
and
vawns and turns it o;er b the juniar resident, then it is 
going to do well
it i" o"Aq n hate a hgh su^ival rat1 tt he look> at the 
injLtrr and
,"ii"l,"r.l.*"t ,""n, ,n;l the 'esidert will have to da some suturing 
and
reallv help the patient, and the moiatly rate witl not be high' and 
he ar she
wil'look gooi during the notuidity'nonatity conference lf 
the tesident
sweats...ihat means that he ar she wilt da a lot of sewing' will 
encaunter
a coiptication, ara witl nave ta defend hinsetf or herself at the 
nohiditv'
-'rf,i"iti, 
"or"nn"" "ro 
probabtv receive a tat at heat And il th. residenl
".--r"rt'" 
,na r"^" for the anendng toLt Ana' hat 
the pahent wi do
(A'n Surg 1990; 211: 673-674)
When vou are operating on a bleeding paiient' it all comes 
down io a
simole question: can you stop the bleedlng be{ore the 
patient runs oul or
iilJai il'" r."v ,o "r"""ss 
is noi how votr handle a vascular clanrp' but'
ralhef. how vou handle yoursolf and your ieam Bleeding contfoL 
Ls not
"Oorr'."oJrnn 
some cool moves lt is ihe ability to rapidly select
appropriate he;ostaiic options and deploy ihem one after 
the oiher In a
discipiined, eflective fashion Here s how lo do it
TOP KNIfE The Ari & Croit of Troumo Surgery
Choosing a hemostatic option
Don t feflexively jump on a bleeding vesselwith the {irsi available ctamp.
Instead, train yourselfto think o{ every bLeeding siiuation as a problem that
requires an effective solution. There is always more than one alternative.
Your job ls to come up wiih a solution ihat will work for the specific
siluation in front of you. Therefore, the first rule of bleeding contro s
always seJect the simplest, most expedieni hemostatic optjon.
Begin with the simplest hemostatic option
Whal are your opiions? lf you have some surgical experience, your list
musi begin with 'do nolhing.' This is often an exce lent choice because
rely ng on ntrinsic hemosiasis works surprsingly well for certain iypes of
minor hemorrhage, like superlicial oozing from solid organs. Your list of
options probably goes on io electrocautery and ligation and ihen gradually
escalates through the use of henrostatic sutures, packrng, batloon
ta..ponade, and all lhe way up to a formal vascular fepair. You will not
insert a hemostatjc sulure unless simpler means have either failed or are
inappropraie. Therefofe, the second undeflying principle is a graded
Bleeding control is a graded response
lf the first soution you chose didn'l work, gradually escalate your
efforts. An experienced surgeon rapidly zoor.s in on the 2-3 best
hernostatic optons for a given situation. This principle of a graded
response has an important corollary: while you deploy a hemosiatic
soluiion, ihnk ahead and prepare an alternaiive in case your selected
iechnique doesf't work. Why is this importanl?
The more complex youf next hemostatic solulion, the more time rt takes
to prepafe. When faced with massive bleedirg from an inaccessible siie,
preparing an alternative becomes crucial. l{ your chosen solution doesn't
work and you are not ready with an immediate alternative, you are up the
2 siop Thot BLeedinsl H
creek in search or a paddre,Havins-a hemo::1h":iTli,',^1ii i;i;t;:
accideni. lt requires careful plannlng ano
iO"iO*"", 
"t,""* 
V." *ill need and where they 
can be iound'
Temporary and definitive control
Temoora'v control is ,il.e plugg ng a ho e ir a 
reaky buckel wr|l- your
t"" . , . "6"t ' i i , ' "" conitol rs l ' ing tne oLrclei ln rassve 
breedirg
,eiolr , rv.onrtot 's r t*ays .ne r ' r5l s iPp becarse r al lows vou 
io assess
ii" 
"ituutlon "nO 
a"ptoy in appropriate definilive hemostatic measure'
Temoorary solutions musl be quick' eifective' and atraumatic 
ln certain
r '^ta"" 
"1"*" 
ft *len tne bleeder is eiil er iraccess'b e or oifl cL'll to
.1"""r . 
""r . I" .06"",v 
cont 'o ' l raneuver (sJch €s pacl ' rng or bar loon
;;;;;":;t ,n;y ;., " "',t 
to be tne der'n'|L ve -Fdsur€ becduse thFre s no
oerter opt 'on. l { vo.r Le'npo'ar ' ly Packed a oadly injJ ed l ivera,rdi t 
s 'opoed
bleedirq, don\ ie-ove rl'e Pachs You 
,lav€ acl'reved etteclrve lFmoslaqrs
- good enough Move on
Be ready with an altemative hemostatic optbn
Obtaining
tempolarY contlol
Manual of digital Pressure
is an excellent first chorce.
Conirol bleeding from a
cardiac laceraiion wilh Your
{ingef. Pinch a mesenteric
bleeder beiween lhumb ano
foref inger. Compress a
bleeding iniernal jugular vein
with your f inger ' lnseri a
finger into a hosing gforn
TOP KNIFE The Ad & Crofl of Trourno Surgery
Have your assistant
compress an Injured
liver beiween the palms
of boih hands. Using
your hands is quick,
instirctive, completely
airaumatic, and very
A classic enor of the novice is to grab a clamp and try to blindly apply
it in a pool of blood. This nevef works. Vascular clamps are effective when
the larget vessel has been dissected out and isolated, not when ii has
retracied inio the tissue or is barely visible. Blind clamping is a sign of
panrc. You will not only farlio achieve control, but also will end up with an
iatrogenic injury Wild clamping o{ the descending thoracic aoira caf
easily result in an av!lsed iniercostal artery. A clamp apptied hastily to the
supracelrac aorta may perfofate the esophagus. Blind clamping of a limb
artery in a pool of blood wil crush the adiacent nerve or iniure the
neighboring ve n. Un ess you are !nusually talented, you cannot perforate
lhe esophagus or crush the median nerye with your f nger
The finger is mightier than the clamp
Temporary packing is a good option for diffusely bleeding surfaces or
caviies. lt also frees your hands. However, packing will not control malor
arierial hemorrhage.
Pedicle control is anoiher opiion. Does the lnjured organ have an
immediately accessible vascular pedicle? The spleen, kidney and lung do,
as does the bowel. One of the iwo vascular ped cles of the lver is easiy
accessible and can be rapidly pinched between thumb and forefinger or
clamped with a non-crushing clamp, the famous Pringle maneuver.
Similarly, if you mobi|ze ihe sp een or kidney you can rapidly conirol the
pedicle with your fingers or a clamp. Twisting the lung upon itself rs a
simple and effective technique for hemorrhage control, asyou wi/ldiscover
later (Chapier 11).
2 stop rhot Breecrine n
Temporary conirol buys you time You can relax 
for iust a momenl' ger
,f'""i,Jufu,io" o".f i*o your compressing hand' 
s!rvey the situation anddecide how io Proceed
Small problem or BIG TROUBLE?
Now thar vo- have galreo tempo-ary conl 'o 'and bood 
' no longer
*r,"" 
" , i "*r 
you, olo"r" , .u" ' rFld you h've 
-eached thF kev iaclrcal
il"i"'"'" ," i":.i.*" conrrol: tn" d st ncliol between 
d smalr prob'e'n
and BIG TROUBLE
A small problem is bleeding you can control using 
a direct hemostatic
nl"n*""t ' f i t " c lamping, sutr 'Lr ing' or reseci ing 
the injured ofgan
H.morrhoqe fror an rr iJ-ed sp'epn rs a smal ' problem aq 
is a p' t roh"ra
;, ' , ; , r"" ; ; ;" . 
" ' " 
; q 'ade ' iver rr i ' r ry ' Tne sred naror 'v ol breedins
"ir,,"",lon" 
you encounter during a trauma operation belong 
In thls
category.
BIG TROUBLE is an entrrely di f ferent kenle of 
f ish-a complex or
inaccessibLe injury ihat poses a clear and immediate 
danger to your
p"'""* lii". e'n,nnn*de liver injurv is the prototvpe o{ 
BIG TRoUBLE
iteeaing from an iliac vein or a posterior intercostal 
ariery deep in the
lower chest are other examPles
The dlstinction behveen a small problem and BIG TROUBLE 
hinges on
" "".Ui*rt" 
of the bleeding rate and the accessibiliiy o{ the bleeder'
;;;", ;" peripheral mesenteric vessels can 
bleed more than a
I""t"t.i- n".""rn" in the base ol the mesentery' 
Yei peripheral
.""""t"ti. O""a-" *" a small problem because 
they are accessible and
"; 
i; d;i;,h. Bleedins fiom the rooi oi the 
mesenterv is BIG
in6ugrr u"""r"" l t impl ies th€ need {or vascular 
reparr oi an
inaccessible superior mesenieric vessel
olt"r.i* it th," lt""aing organ has a vascular 
pedicle
TOP KNIfE The Arl 6 Croft of Troumo SLrrgery
The upper abdominal aorta s difficult to access and control; therefore,
a midl ine supramesocolc her.aioma is atways Btc TROUBLE,
regardless of how much rt has bled. Free hemofrhage fronj the
retrohepaiic veins ls BIG TROUBLE, not onty because it is fast and
fur ious, but also because you cannot get to i i . Accessibihiy depends on
the pat ient 's posi i ion and on your incision. For example, an injury to the
posterior thoracic wall may be inaccessible from an anterolateral
thoracotomy incson, but easy to reach through a posteroaieral
ihoracoiomy,
Learn to distinguish between a small problem and BIG TROUBLE
Small problems and BIG TROUBLE fequire di f ferent mindsets and
different operative approaches. You can tackle a small problem directly by
immediaieLy deploying appropriate hemosiatic solutions until the bleed ng
stops. One of those soluiions s likely to work, and the b ood loss wi| be
l imited.
lf you j!mp if and go head-to,head wlih Blc TROUBLE, you tose. The
patient is profoundly hypotensive from niassive blood loss. The OR ieam
has no idea how bad the stuation rs or how you plan io deal wih it.
Exposufe is bad. The 10-12 units of blood the patient will need afe st tt n
ihe bLood bank. The vascular insifuments you will need are siored outside
the OR. In other words, the odds are overwhelmingly siacked agalnst you
and your patient even before you begin. A frontal aitack (as you did for a
smal l problem), wi l l be l ike a bungee jump wthout a cord. Unless you do
someihing to even the odds, you're f nished before you siari. So, what to
do? The answer may surpfse you.
2 stop Ihai BleedinsL I
Update
Once you havF gained te-po arv co' Irol_ 
STOP' Res:st lne templal ion
," I-.""a1"*,, p,"J""" to de 'nrLrve 'ontror' 
Ins'ead orgarrTe ard oprrm:ze
your atiackl
. l"l::T,:",",."jf il:x'.:JxilJ,",.'fi"1'J"':;ii::J::,:fi:':".,:l:X1
least 8_10 units of blood and a raprd lnruser'
O Ger an a.rovans us;on dev:ce 
p i-ed and wo'(lng
; :li:;*".::;"n,::il fl:"';:11",":ili:1"11:'#;;:i:ll
. "J*m.J1';;x;14 l+i!ill:.#.'":,,# 5l ;: x:
addit ional equipmeni l ike a Foley or fol
. X"'S::"'H"#;;ffi:Jil!:f"""; '"".' can thev handre the rorreF- 
1""",* l.lJ" ai""at should vou set additional f"uFfi"""ning u ""r{-'',:,:f ;::ii::ff iJ'il'"'#J"t'1i11",,*"""*"
While all ihese preparations are moving 
forward' don't fiddle with your
,".o"i"tt 
"""i,J 
L"""" the packs alone' maintain manual 
pressurer ano
don t move any clamps
Don't fiddle - be a rocx
TOP KNIfE The Art 8 Croft of Troumo Surgery
Siand calmly and patientJy wjih your hand on the bteeder and wait unril
the ieam is ready, the patient has been resuscitated, and ihe appropriaie
rnstruments and help are in the field. you have carefujly set up youf attack;
now wage your battle under favorable circumstances.
When_dealing wrth Btc TROUBLE, resist the temptation io keep onmoving. The drama of exsangLrinating hemorfage rs s(jch rhai the ieama\pecls you lo 'do sometning. stopo;ng lhe ooeraion in mid-ar-,s l .e lasr
Irrrg they e,oect. Neve.tretess. Instst on co_p,erng at prepa.arons even
if it takes a considerable amount of time. We have occasionaily stooa witi
our hand on the bleeder for 15 minutes or more whi le the OR ieam
co-'rolelFd p.eparat,ons fo, baflte ard -he oat.elt was being resrscrtatFd.-are1uF. prepa-at,on ard olann ng give yoJ a huge tacl ica. eova'r ldgF a'ro
dramanca ty improve your palent s chances,
We cannot overemphasize how criticat it is io distingutsh between a
small problem and Btc TROUBLE_ This may we be the most imporiant
decisiof of the eniire operation. ll is often a sublectrve decision that
oepends on your experience and confidence. A situaiion that a surgeon
with limited trauma experiefce considers BIG TROUBLE may turn o"ut to
be a small problem for an experienced co eague. Nevertheless, if your
impress/on is thal ihe situation merils an organrzeo attack, you wiil never
go w-o19 oy dporoacri"g r t ar Btc TROUBLE.
Selected hemostatic techniques
Pdckitlg 701
Packing is one oJ the most underrated and badty taught iechniques in
Ilula 
su]Sery. lt is also one of your best weapons fof deating wiih BtG
TROUBLE. Surgeons tend to think of packing as such an intuitive skill that
they rarely bother to teach it properly. After all, you don,t have to be a
surgjcal genius to stuff some pieces of cjoth afound a bleeding liver _
wrongl
Always err on the side of caution
2 stop lhot Bleedinsl n
The fitst rule of packing is io do ii early.since 
packing relies on'clot
"rril,""l',i "* ",i,, 
l" Jtfective if done when the patient can siill 
rorm
n""J"[i'" t"lnan "" " 
last resort' when the patient is coagulopathic and
oozing fronr everywhere, is futile
There are two main ways io pack Packing fron 
without is c]eaiiq a
sandwich. Packing from lthin is filling a cavity
Pack from withoui bY
placing laPatotomy Pads
outside the rnlured
organ to reaPProximate
disrupi€d iissue Planes.
To achieve effective
hemostasis You must
create lwo opposing
pressure vectors that
compress the injured
iissue between ihem;
otherwise, Yout Packrng
wlll not wofk. EffeciNe
packing is a sandMch,
Tn.e recn'1ique " mosl 
olier used ;n the :nrured livet A good sandw cn
arouno t l 'e l ive- cons sts o' iwo rayers o' laParoto-y oads 
{aoove ano
U"to* o, 
"nt"riot "na 
posierior), apptoximaiing the disrupled tissue planes
O"*""" *". t** ,Vefs are suppoded' in lurn' 
by ihe abdominal wall'
i* a:uprlrug,n or by adracent aodom:nar organs 
s'icl- as ihe slomach or
l^roe bowej. You cannot c'eate a good sanow cn by 
Laigrrg two p'pces
ni"t,""o ,n n-,0."i-. Vorr 
"andwich 
.nust -akc mechanical sprsF
)
TOP XNIfE lhe Ari I Croft of Trourro Surgery
Packirg from wihin is
stuffing a crevice or an
acilvely bleedjng cavity with
absorptrve gauze. The filling,
consisting of an unfolded
gauze rol , is push ng
ouiward against ihe walls of
the injured parenchyma.
Your packing technique
must be iai lored to the
shape of the injury. lf
deal ing with a large
bleedlng surface or mu tiple
injur ies to a sol id organ,
pack fforn without. When packing a beeding crevrce, like ihe deep
perineal wound of an open pelvic fracture, pack from within. ln severe liver
injuries, such as a siellate fractufe of the dome oJ the rjght lobe, you will
otten find yourself !sing a combination of both techniques.
Packing from without or within worksin oDDosite direction
The thifd rule of packing is io avo d overpacking. While construct ng
your sandwich around the inlufed liver, pay special atteniion io the
paiieni's blood pressure. lf it suddenly plur.mets and the anesihes otogisi
shows signs of distfess, your packs may be compressing ihe inferior vena
cava (lVC) and diminishing venous return to the heart. Caref| y remove a
few packs and reassess.
Too much packing is bad
The fourth (and ast) rule of effeciive packing is to be paranoid. There
rs aways the danger that your packs willfot work, bui it usLta ly takes time
to find out. Laparotomy pads have an amazing absorptive capactty, and ihe
patient may wel/ continue to bleed lnderneath them. lf the patiefi s
physiology allows, spend at least a few minutes doing something else, and
2 srop rhoi Bleed.q n
t:T;:'il";ift i"J::"::,,,1"if ':T':J ::;il,:i f :: il":ff; :[';
.,"*1,,*.lat U )/"., *" not sJ-e 
peer.o{i the -ost supef;urallayer ot the
l"naiui"t' 
"na 
tul" 
" 
good look at the deeper layers Are ihey turnrng 
prnK
lij-rno'"tf 'f *, yo, h*e to take the sandwich apari 
because you oo nor
n"ue ette"tive le.ostasis Never rely on the patienfs 
cloiting mechanlsm
i" 
"".0"*t" 
for ine{fective packing The besi time to ach 
eve
l"#iJJ i" r"*" vou leave the oR' noi iwo hours 
(and 12 unds or
blood) Later'
What if your packing doesn t work? Fitst' remove 
the soaked packs
*" u1l o""'*a l*p""ithe injured area.once more 
Did you have a gooo
sandiich sotiaty supporied by surroundlng siructures' 
of did you build a
"f_to"ting 
""na*i"l',' 
in .id_air with no support? Do you need lo add 
more
o"'"-f."iSf,ouf a vou uaa packing {rom within or lrom 
wlthout? ls lhere an
ii"''"i 
"-""J* 
,i' tn",",,'"a a'"at lttlre'e is' yo' musi dealwiih it 
directlv
,"1"" 
"""n"i 
*.*"i'c technique can you do something eLse 
to help
i.t',a" aii"o'"n" naa a topicat hemostatic ageni? 
A blind hem.ostalic
"r,lr"" 
*"t""u 
"""0 *"it ag;in uniil you are sufe that you have ef{ective
bleedlng conirol
I serting a blittd helnosttltic (figrre of 8) suture
Use a blind hemosiaiic suiure to conitol a bleeder 
ihat is eiiher invisible
o, ias retract.a inlo the tissue You cannot 
see the bleeder nor can you
;;; ;;;;;. 'i, but vou can imasine whefe 
it is After usins brrnd
t',".o"tuti" 
",ltrt"" "o 
*any iimes in eJective.and emergency surgeryi 
you
.uv f""i"onfia""t tl"t vou know ho* io do 
ii well Chances are' you
don'ii here are some useful pointers:
a Make sure the anatomical situation is 
aPpropriaie for a blind
' 
;";;;; 
";*". 
lf the bleeding is close to an unexposed 
malor
"""""i "f*"y" 
assr.rme that lhe maior vessel is the bleedet and
Be paranoid about Your PacKs
a
TOP KNIFE The Ari & Craft of Troumo Surgery
lJse a monofilameni suture that will slide through the tissue rather
than saw ihrough ii. Strange as it may seem, the keyto success is not
ihe suture, bLri the sAe ofthe needle. Choose the biggesi needle that
is appropriate for the situation.
a Place your first biie as close
as possibe to the sil€ of
bleeding. The purpose of
lhls bite is not to achieve
hemosiasis, but to gain a
good purchase on the tlssue
so you can litt it up by gen y
pulling on the suture wlih
your non-dominant hand.
Now you can see on which
side of your first biie the
bleeder is spurting. Your
nexi bi ie wrl l be for
hemostasis, and since it is
wel l - targeted, i t wi l do
usefulwork,
lf anyone ever bothered to teach you about blind hemostatic sutures,
you pfobably know that your aim is to end up with a figure of I
corfiguration that runs under the vesse proximally and distally to the
bleeding site. This is nice in theory, but in praciice you can never be
sure in which direction the bleeding vessels lies. That's why ihey call
i a blind stitch. Don t be disappoinled if you end up need ng more
biies. ll is okay to inseri 3-4 bites instead of two, as long as the biies
are cose together and lhey work. We cal ihis 4-bite suture a 'figure
o f 1 6 . '
Often, pulling on your blind suture w ll siop the bteedirg. You must
then decide if you wsh to use it merely as a temporary hemostaiic
maneuver or te f as a permanent soluUon. l f you decide to t ie i i ,
remernber to eave the ends long because you may wish to remove t
later.
While insert ing a bind stich, plan your next hemostatic alternative.
Experience has taught us ihai il you have noi obtained hemostasis wjih
a
2 Stop Thot Beedins n
Aottic clafiPittg
Ao ic clamping is one of the traditional heroic 
maneuvers in ifauma
suroerv. Use it eltier as an adiuncl to resuscitation in 
a crashinq patient or
i*"oriur pt.*i..r contfol in rnajor abdominal vascular 
lrauma You are
'-.'i"l' '. i*- r'.. - oroperlv co'rlrolll-e sJoraceriac aodom:ndl 
aorta i
V"" " t i "-oi ' i 
. t Ln" l i 'sr ' ime-ir a berlv lul ol blooo LFarn and orauL'ce
the lechnique under eleciive cifcumstances
Use aoriic clamping judiciously, noi reflexively 
When used as a
resuscitative adjunct' ii temporarily corrects 
the numberc on the blood
0r""""t" t*it"t, O* "t 
the pfice o{ global visceral ischemia
four bites, you are not likely to achieve ii 
with ihis siitch Don'l Jlail' Try
something else
As with any maior bleeding,
the best inrmediately avaibble
tool is Your hand Pull the
stomach downward and bluntly
enter the lesser omenlum In rc
avascular Poi(ion. Feel the
aorta Pulsating imnrediately
below and to lhe right oi the
esophagus, and compress it
againsi the sPine. lt You are
occluding the aona as a
resuscitalive maneuver' manual
compression is often good
enough. li Yotl need formal
aortic control, Proceed wiih
transabdominal suPracellac
aortrc clamPlng
filTf,I[of " 
h..ostatic stitch sains purchase on the tissue
TOP KNIFE The Art E Crofj of Troumo Surgery
The key anaiomlcal consideration in supraceliac clamping is that you are
cjamprng the lowermost thofacic aorta, but doing it ihrough the abdomen.
As lt emerges between the diaphragmattc crura, the aoda is enfotded by
dense neural and fibrous tissue. In this particujar aortic segment, it is
difficult to obtain a good purchase wiih a clamp wiihout dissecting around
the aorta. Your best bet, iherefore, is io go higher up, into the lower chest.
Clamp the lower thoracic aorta through the abdomen
lf you have time, mobilize the
left lateral lobe of the liver by
incising the lef t t r iangular
l igament. Thrs improves youf
work space bui is not essential
to gei to the aorta. Biuntly open
the lesser omentum immediately
to the right ofthe lesser curve of
ihe slomach, and insert a
Deaver retractor into the hole.
Retraclion of the stomach and
duodenum to the left exposes
lhe posterior peritoneum of the
lesser sac and, underneath it,
ihe ight crus of the diaphragm.
Palpate the pulsating aorta
above the superior border of the
pancreas to or ient yourself .
Blunt ly make a hole in the
poster ior per i loneum; then,
using ei ther your Jinger or blunt
lipped Mayo scissors, separate
ihe iwo limbs of ihe right crus of
ihe diaphragm to expose the
antedor wall of the lowermost
2 slop rhoi Bleedingl I
Using the fingets oi Youf left hand'
create just enough space on lrom
sides of the aorta to accommodate a
clamp. That is all the dissection you
need. Take an aortic clamp ano guroe
it io the correci position using the
fingers ol your leJl hand as a guide'
Clamp, and check ihe distal aorta lor
The aortic clamp iends io lall
forward inio the wound Encircle it
with an umbilical tape and secure the
tape to the drape over the Patrenfs
lower chest to immobilize the clamp
T H E K E Y P O I N T S
) Begin wiih the simplesl hemosiatic 
opiion
) Bleeding control is a graded response
) Be ready wiih an alternative hemostatic 
option'
) The finger is mighiier than ihe clamp
> Determine if the bleeding organ 
has a vascular peorcle
) Learn to distinguish belween a 
small pfoblem and BIG TROUBLE'
) Don t f iddle- be a fock
) Always err on ihe side o{ caution
'fr 
to, *"nr rn. ̂ rt & crofr of TroumoJurgery
!
I
Chapter 3
r - T t 1 1 , : r
Your Vascular loolKlr
Hutuall beings, who ate almost utique in hazting 
the
'ot,ititu 
to tria froa th? etpeie (e of olhe$' are atso
i; ;' ; k;i i ; i;; ; i ;: ; ; ;i p pi'[ n a i s i' ci i' a r i o n t o d o' o
- DouSlas Adams
lmaoine voJ'se p,eparlng Lo 
'epair a gunsnot injury lo ihe Iemo-al
""";;il; 
;;:;;; patieni has ar arte-ioveno'rs tisrLla 
jus' berow Ihe
il;is;"i; Yo,u feel a strons thrill and 
hear a bruii definitelv what our
residents call "a greai case 
'
You have a small probleml no angiogfarn oi the injured 
area Com€ to
,l'"0 ot ir, rou have neither heparin nor monofilament 
suture You doni
"u"n 
t_"ua 
" 
o-o"t u"""Llar clamp Your greal case is 
'aoidly becon'ng a
nioit.".". Ho* wourd you leel ;' the on'y vasuula- ools 
you hdd were
",r"." 
ti* 
"orron "utr,res 
or stra'gnt need'es ard a oai- of cr'ide non_
crJshino crdmps? Can you 'naglne graobirg a sca'pel and lus'g-oirg 
lor
ii.l"i-,i"J """'" 
I l'.'is exactiv wnar J B Mu'ohv dn ama?irq cFicago
;; ; , i l ; ; ; ; ; t H" r xed a remorar arenovenoLs i istrra 
armed olrv
f f ; ;"-" ; rro* 'eoge ol tne analomv' vea's ol 
practrcirg vascLlar
repai's In .he laboralory. and sheer gJis Tne operaiion look 
2 9 rours ano
went smoothly with no compLlcalons'
More ihan a hundred years laier, you have a dazzling array 
of vascular
instruments at your disposal when facing maior vascular 
trauma But you
"""""i 
.".. i"'"" 
" 
f"i"fated poPliteal artery and forget that ii belongs to
a criricatty inlurea patient who also has a fractured 
pelvis' a contused lung'
and possibly an inlracranial hemofrhage'
Tn,s cnaoter wi l , l r - t acqJarnt you wt1 Lseru general 
pnrc'ples [o
. ' , .J" 
"o, 
*n"n coming lace_lo_lace wth a vasuura' n 'ury ' 
We assLmF
J"" 
"r." 
=.i i.r. * t. o"iic va.cu ar recnrioues ano will show 
you low lo
liroi i"" i" +" u*-. s lJat on secono' we wrll 
p'esent a u"efrr toolkil
TOP KNIFE The Ad & Croit of Troumo Surgery
of technical oplions for damage control and definittve repair of vascular
injuries. Remember, a good outcome n vascular trauma depends .fore on
clear thinking and keeping piorities slraighi than on cool gadgets and
elegant moves. Keep your vasculartoo kit in mind as you learn to dealwith
specific vasculaf injuries in subsequent chapters.
Sequence and pliodties
Much l ike any oiher trauma operat ion, avoid making 'exci tng
discoveries' when dealing with major vascu ar inj!ries by following a we[-
defined sequence of steps.
Bleeding
Conlrol
Bleeding and schema, ihe two manifestatio.s of vascuar trauma,
represent diffefent priorities. A bleeding carolid artery is an immediate
threat to the patieni s life, and you must control it NOWI Not so with an
ischemic eg from a superficral femoral artery injury, where you have a
w ndow of several hours to save the leg. Th s is why bleeding js part of the
ABC of the primary survey of the injured patient, while ischemia isn't.
Bleeding and ischemia are different priorities
Grafr
,<v ?
)J ,,t,,^ )t ./a- Io g o { _ T J + ( f p i
Ext€nsile Delinilive
Control
Decision
Control external bleeding
Obtain initial control ol
external hemorrhage bY simple
digital or manual Pressure' lf
possible, rapidly iransler resP'
onsibility fot comPreasrng rne
bleeding vessel to an aaslstanr,
and preP the hand as Part of
the operaiive field Your
assistant can then connnu€ to
apply pressure while You make
an incision Proximal io (or
around) ihe comPressing hand
to expose the iniured vessol
g vour voscutor roolkii I
groin, supraclavicular fossa'
axilla, or neck. In these
localions, manual compression
is less offeciive. lnsert a Foley
catheter into the bleeding
tract, inflate the balloon unill
bleeding stoPs, and lhen
clamp the main Port of the
Foley. lf the wound is wide
and the balloon PoPs oul'
approximate the wound
edges around it with a stilch
to help hold it in place
Use a balloon catheter when the ble6ding source 
is deep and the wound
" 
;;;;;. ffii;;;nd), especia'v in transiiron;"J:L?,:::::;^:,1':l:
(t
I \ l
\l
r*
-" *n t"aponud" *ntrols external bleeding 
in kansition zones
TOP KNIFE The Ad & Crofi of Tro!mo Surgery
Before you begin
Do not beg n a vascular exp oraiion wthoui comp ete knowedge of the
patient's trauma burden. How much iime has passed since the injury?
How much has the patieni bled? How urgent s the bra n contLtsion? What
is the plan for the fraciure if the extremiiy you are operating on? you must
incofporate all this lnformation into your decision-making or you wi end up
wftn an awesome vascular reconsiructron - rn a dead paiieni,
Know the patient's total kauma burden and physiology
Proper sequencing is a huge factor in penpnerar vascular trauma
because injuries to |mbs typicallyalso i/rvolve oones, nerves afd soit trssle.
As a general rue, bone alignment conres before vasculaf repair. Fixno
fract-res invo'ves s,ch lLn acLvtres as ha. rer i rg, r immrrg and ct^ iser ing.
moving bones, and other tricks that a sio suture line does not toleraie very
wpl l . So, i l lhe hmb s.or grossy 5cremc ard ihe pdnred orhooedi;
procedure is short re.g. erter'lal frxatronr, let the o.thooediu sLrgeor do h
before the vasc!lar exploration. tfthe timb is grossty ischemic or ifthe injury
is actively bleeding, you have io go f rst. Controt the injured artery, insert a
temporary shunt, and do a fascioiomy io increase ihe tolerafce of the limb
io ischemra. Let the odhopedic surgeon achieve bone alignmeni, and onty
then do the deflnitive vascular repair on a stabte extremity.
Align bone before aderial reconshuction
Angiography
Preoperative angography is noi an option for a hemodynamicaly
lrnsiab e or actively bleeding patent. If a stable patient, get an ang ogranr
d you can, especially if you aren't sure where the injury s. Consider a
patient wiih multiple gunshot wounds or several fractlres n the same
extrernity. How willyou know where the injury is without a road map? With
a srngle penetrating injury, ihjngs are sjmpler because you can find ihe
injury wiih a limited exploraiion, so you can skip the angiogram.
3 Your voscuLorroolklt H
Depending on your experience and the local citcumstances' 
you have
three options for obtaining an angiogram:
1. A single-shot angiograri performed in the ER 
_ rapidly becoming a
losl an
, e"i",r"r study performed in the angiographv. 
str l : 
":^^9:_ 
"ndovascular 
inierveniion could preclude ihe need for open 
reParr'
a ;;;;;;" ansiosraphv b1, cannulalion 
of the exposed aderv -
" 
o""il!"rn" 
"t" 
oL ai"ned by clamping the inflow beJofe injectrng 
the
dv".
Pre-emPtive f asciotomy
Consider doing a fasciotomy before beginning 
the vascular reparr' nol
*f,i" 
"".p"*"""a "v"arome 
L clinically obvious When operaling on an
i""t"." ,r'ri "ttt, ,;, 
.ften know ihai the formal repair is going to take
ii"". i""r. ""f""'""""" 
of action is to do a pre-empiive {asciotomy
A popliteal adefy repait is a good examPle' 
Regardless ol your
"rp.rlni", 
poprit."it""onstructions always end up taking longet than 
you
"ri"li"o 
in" unforgiving naiure -of 
these iniuries and ihe paucity of
collaterals around ihe knee vrrtually guarantee 
yor'r will noi finish this
;;il il;"i a fasciotomv 
Be smart Do it before the vascular
we do a fourconrpartment fasciotomv using I 
d:]bl: 
Jl"l:i::
*"';q; Pr""" vour iaterar incision :tC'*'l"lfll,y-:"1':::::i11"li:rcia all the way down to the
tateral ;o rne edgF o' the tbia OpFn the 
ras
""ni"' 
,f,"", 'a""ity and incise the inlermuscular ::t:l#*f^-+*H
;;;;.;;"; 4t","' "o'p"'i'"'.t' 
Avoid da-ase to rh
rve ihat lles l! imity io th
of ihe fibula\ Then, make a
ffie 
medial edge of
;; an angiogram if the patient is stable
t<z$ol'.. =r
ToP KNIfE The A.t & crofi of Trourno surgery E cf"^h 
'<-?tw^
. a / , . /
to lhq greater sapherfous veiny'nor pad of tnis
Usrng'lhe cautery..6erach the loleus muscte iro,r1
the modial aspect of ihe tibja to decompress the deepposterlor
compartment.
Extensile exposure and key landmarks
The fundamontal pr inciple of vascular explorat ion is extensj le
exposure, which means ihat you must be able io extend your incision
proximal ly or distal ly along the same axis as ihe of iginal incision. The
the iibial shaft. Injury
/ncrsron, so be cafoful
obvious examples are
lower extremity incisions
along the medial aspeci
oi the leg. Using ihese
incisions, exposure of
the superftcial femorai,
popht6al, and Ubial
vessels can easily be
extended into each othor
In ihe upper extremiiy,
subclavian, axiJlary and
brachial exposures are
similarly extensile. Avoid
non-extensrle exposures,
such as lhe poeter iof
approach lo the popliteal
ve$els or the transaxillary
approach io the axi l lary
artery, because they limit
your access and restrict
your opiions.
Do pre-emptive fasciotomy before poplitear anery repair
3 Your vosculor Toorkil H
..H::1,::::""J l'"3:,i:'::T ;T"""l"li :T'J"'n::;l l:1 iT.-:l
:f i:::it'::".m,:*if:i:' ;: J,::':::iT:fl :i::;
;::ii:rtli:l'*::J::"1fi ":lil;:15::TJl:,""":':.,:ff :
a"ria""'t a+Oq* Find lhe posterior aspccr ot tne 
{emu' or libia' and
i""'-ff :*-::rm"""Jff .;ff i;111"T:J-'j:ff ::;:ll"Jl;
t*ff ffio.*"",*": jT;:iT::'.*:"??"Jt"1li?;,lli.il,Tl
;"i #;;;;j';" ;; "'tremelv 
'rse{ur concep' whe. vou r€ n troubre i.,'
unfamiliar territorY
Proximal contlol and anatomical barriers
What is definitive vascular conlrol? ll is the accurate 
placement ot
u"""ri", 
"t"tp" 
(or olher atraumaiic means of occlusion) across tne
i*t* 
"nO 
outffo" tracts of an iniured vessel Proximal control 
is key
Fnrrrino a nematoma w[no,, ,''"' oot"'n'nn O'o''tar Lonfo away 
lrom the
lt"".li"rr" '" 
" 
ur"" mislake thai often leads Io excessive blood 
oss
J^"rn"t i :"a tumor;ng pan c :arogenic InlJry' 
a ld soFetrmes
Prevent voJr drssecton {ro- beco'nlng a search ano oestroy 
m ssion
O, 
"it"';"g 
orox'r"al conrrol o'risrde tne hematon'a Il'aI surrounds 
tre
ti,-t. 
""t:" 
l" 
"'"g" 
terrrlory where tissue pranes are norrnal and
giaiua,ty aouan"" tow"td tne n;ured seg-ent
Experienced surgeons go beyond anatomical baniers 
lo get proxlmal
""*rli 
V"", you iu""""J it ' another key concepi 
Many anatomical
"irultur"" ""*" "" 
u"t'iers to the expansion o{ hematoma consider 
the
Know the key an6tomical landmarKs
TOP KNIFE The Art & Croft of Troumo Surgery
inguinal ligament rn penetrating
injuries lo the groif. Betow the
lrgament you wi l l f ind only blood,
sweai, and tears. Above it, you
are in vtrgin territory where you
can eas ly isolate and conirolthe
external iliac artery. The peri-
cafdium is, similarly, a barrier to
the expansion of a mediaslinal
hematoma, and the diaphragm
blocks the extension of a midline
retroperitoneal hematoma. Go
to ihe oiher side of anatomrcal
barriers to {ind easy proxima/
A useful opiion for proximal control in the limbs, often fofgotten in the
heat of battle, is a pneumatic tournrquet on the upper arm or proximal
thigh. Usirg it sar'es olood and sirnplifies rhe d,ssectio.r. Orce vou have
isolared and c amped trp irlrred vessels. def ate tl-p toLr'l,qLer.
Distal control
How importani ls distal control? li depends. Usually pfoximal control
alone does not dry up ihe operative fietd because back beeding fronr the
dislai vesselcontinues to give you grief. The patieni wil not exsangurnaie,
but you will not be ab/e to do a vascular reconstruction in peace.
For ihe aorta and iis proximal branches (e.g. subclavian and com..on
i|ac arteres), proximal c/amping serves only to convert fierce audible
bleeding into weaker bleeding, but you still cannot see ihe injury well, and
ihe patieni is losing blood at an alarming rate. you mlsi obtaln distal
control. Do ihis outsido ihe hematoma if you can. lf not, expose the injury
Get proximal control outside the hematoma
unde. pro).ima' conkol and gai4 d stal control 
lrom within the I'emaloma
i""'"^i to"rtion, wne-e distar conkol is dfticult 
are the distal rrle-nal
"'"loiio "i"rv, 
.uu"t,ui"n artery and the a'ge verrs ol the 
pelvrs
For distal conirol {rom within the hemaioma' choose 
the technique-thal
mt"l';li:xru!T;i"1,fl",;"il1ll'ff :;i'f i:"il;",ii;
l"*# fiol""|lt li"n"rtv cathe-ier connected 
to a 3'wav stopcock) rnto
ii" 
"rrrr"*i ""tf 
ffti" l"st techn ique ' frequently used in eleclive 
vasculaf
" "*rV 
"ff""" 
y"" 
" 
n"in distal controlwithout having 
to dissect out the
Exploring the injwed vessel
3 Yolr voscuorToorki i n
Your saJe dissection
plane along an artery
is the Periadventihal
plane directly on the
arterial wall lt will
carry you saJely from
uninjured terrltory lo
the injured segmenl
without lacerating the
vessel or ripping off
branchos, You know
you are in this sa{e
plane when ]/ou see
the pearly_white arlenal
wall wiih the vasa-
G"lnillotr.inut u"tloon for problematic distal 
control
, - r ' - . } . : : i
Vf-=,,au
IOP KNTFE The Art 6 Croft of Troumo Surgery
As you enterthe hemaioma, de{ine the injury by rapidly answering thfee
quest ions:
a Which vessels are rnvolved? Artery, vein, or both?
a How bad is jt? Laceration or comptere transeciion?
a Where are you? Are there ma]or branches, joints, or other structufes
nearby?
You cannot assess an arterial injury by external inspectton. This is
especially true in blunt traumar where the artery may appear intact on the
ouislde yet hide a disrupted intima on ihe inside. you must open the artery
and define ihe extent of intimal damage. With few excepiions, your
arteriotomy will be .long itudinal. Make sure you see the full length of the
int imaldamage.
Once you have defined the intury, carefu y debride the injured walt back
to healthy iissle. Don't compromlse on intlma that looks ,almost normal,
or is slghtly bruised,' because you are buying yourself and your patient
eany postoperative thrombosis. There are no grey areas here - the rntima
is either healthy or it's not.
Define the full extent of the vascular inlury
Developing a work space
Remenber ihai you are not oxplorlng the injufed vessel iusi io have a
lool ar,t. You are gor'1g lo wo-.( or ir. ano you 'leFd a worl space. A
laparotomy or thoracotomy automatica ly provides you with an oper cavty
lhat is your work space. In rhe errremiries ano tl^e rec(, tlere a.6 10
ready-made cavities, so you have to ca e one out,
Develop your work spacs in siages. First, make ihe incision. Then,
deepen it into the subcutaneous tissue and rncise the d66p fascra. lnsert
a self-retaining retractor and continue your dissection to isolate the
neurovascular bundle using ihe key tandmafks. As you make progress,
coninuousty reassess youf emerging work space. ls the incision lonq
enough? Shoulo yoJ re ocare rhe se{-relaining refa{,to. ro a oeepe;
3 Your voscuror Toorki El
ffi:Hlii!## ::: ii:+: H :iH3T*"i"".#[:in
lT,',Ji[$i..""?TJ"T""i"'.1"*Y,"i.'$:l*l*ruru[lt:*:"ll:
infi:,:H:""j;H' l[, ;:::::[:T*, ,ne incision and optimize
The key strategic decision
Now il s tirne for your strategic decision' the choice 
between vascular
aamaoe control and definitive repair - a simple enough concepi' 
but otten
a iougn declslon
Frrsi, consio€t the tyPe of -epai reouieo Fo'mal vascular 
repairs come
.n '*o ii"*,", "i'p" ino :".0 * I "lTllljllii":.i: :?:;:",*:::l';lrne thai can b€ completed quickly even uno
such a lateral repair will work _ just do it
A complex repaiis a\tascular anastomosis 
(or mors ihan one) Anend_
a-"nJ 
"n""toto"i", 
a Patch angioplasty and an iniePosition 
gratt are
:*it,:",:x;ir*:ll:':;;JJ3#i;i:Jl::'i"'"iT::;",'::
;r;'e;';;.';,"ft '; 
"..egu'opath 
c pateni wno wrlr ;ust breed on and on
i--',-* 
"",r.i" 
,t* tniJPaiieni needs io be in the intensive care 
unit'
;;;;;;;; '"""""''"ted not or the ope'at'ns 
tabre rosins more bood
"'"i 
i""ot ng ptog*""'ve'y hvporl'€tric Ynu'nusl 
ba l oui
Second, consider addiliona laclors ls tne 
paiienl unslable or'acrveLy
fr"iorg i" 
"n"th* "*'ty? 
ll il'e arswer is ves -damage 
cont'o,s-your
:lll'i::;":"",",::l;J;'R::'"fi::.il"J"',:XT,,m"iif :'"XnX'i:
,"" 
"t in""" 
0"".*"" ' l no' aga'n choose damage corlrol
Gradually develop and optimize your wolk space
illlilil"",, "o.otex 
va3cular repak and damage control
TOP KNIFE The Ad & Croft oi Troumo Surgery
Vascular damage control techniques
The two major damage controi techniques for vascular irauma afe
lJgatron and shuni insertion.
Ligetion
Ligation of an injured vessel is olten a no bfainer. The exlernal carot/d
artery, celiac axis, and iniernal i iac artery are obvious examples of arteries
that can be ligated with impunity. Other arterles, such as the subclavian or
brachial, can be ligated wlth a low risk of limb{hreatening ischemia. lf you
are forced to bail olt bui plan to repair ihe vessel tater, don't ligaie ii , use
a temporary shunt instead.
Ivlosi large veins can be igaied wjih impunity of with accepiable
consequences (such as leg edema). In ihe past, repaif of the popliieal vein
was vrewed as cr!cial for a good outcome with popliteal adery
reconstruclion, but this sacred cow was slaughtered long ago. Thefe are
even reports ol successful ligation of the podal vein, although this ls
probably one of ihe very few visceral velns ihat you should repair if you
can. Remember, ligating a vessel is not an admission of defeat; ii can be
a sign oJ good jLrdgment.
Ligation is not an admission of defeat
Tefiporary sh nts
lf you have liltle vascular experience br are operating in austere
circumsiarces, a temporary shunt may be your best opiion. Insert a shunl
when the patient's physiology is prohibiiive, when orthopedic alignmefi of
the bones precedes ihe aderial repair, or when you lack the resources to
do a complex reconstructon.
Shunt maierjal is not an issue; use whatever is immediaiely available.
We have successfully used pieces of nasogastric tubes, suciion catheters,
3 iourVorcuor roo ht E
cafotid shunts, and silastic Tlubes We 
preter to use an Argyle snunl
illil"tr" in"l ir*io""ause we use it-resularlv 
in carotid sursery' and.
,; . 
"^"" 
t" handte. However i-l ore oI Lhe most soeclacular cases 
oi
-ri""".il 
""*, "n "" 
we have seen a niltdry surgeon in he lield 'sed
l-segment or naso;astric tube to shunt a transected femoral 
artery in the
grorn.
easier to control than fore{low). Now, fix ihe shunt in 
place The simplest
technioue is to secure the shuni to the artery proximally and 
distally with
n"1"" 
"ir 
,"" Howeve- th:s s taumaliu to lhe drle'idl wal a,rd wi| 
ater
,*rit" 
".a,**, 
O"O*emerI of the artery oeyo']d rhe rigalure line when
".1':".""" 
tl" snr,r-. ol prelerence is Io pass a vessel loop twice
aro:nd tne s 'runted ar le 'y and gent 'y ci lLh f w1h a large mela'c lrp 
or a
nrmm"t tournlqret. Now' asless the dislal perfusion by 
lisiening for a
Doppler signal over the outilow artery You fe done
Shunt failurgshortly aJtef insertion is due io one of the 
following:
a lnadequate infLow (proximal injury or tesidualthrombus)
i Compromised outflow (residual clot or mlgratlon of the 
shunt into a
disial artetial branch)
lnsert the shunt using a
wel l-def ined sequence ol
sieps. Begin bJ/ clearing the
inflow and outflow tracts of
the injured arlery wrth a
Fogarty caiheter, if available lf
not, gent ly squeeze the
proxinral and disial ends of ihe
iransected artery lo exPress
clot, and release the clamps
momeniarily to flush out botl
inflow and outflow Choose a
shuni of the largest d|ameter
ihal will fii comfortably in the
vessel, t r imming i t io the
desired length. Genily insert Lt
into ihe distal, then Proxrmal
artery (since backflow is
a
a
TOP KNIfE The Ad & Croft of Troumo Surgery
Obstructed shunt (angulatron due to excessive length or ligatures ihat
are too trghil.
Shunt dislodgemeni (presents as a rapidly expanding hematoma).
Clear lhe inflow and outflow hacts belore shunt insertion
Def initive repail techniques
You have ihree opiions for definitive repafii endio-end anasiomosis,
palch angioplasiy, or interposriion graft. An end-to-end anastomosis
sounds like an gxcellent choice because rt involves only a single
straightforward sutlre lire. Ljnfodunately, with experience you will lind
yourself using this solutior less frequently ihan you think. In young
patients, the ends of transecied arieries retract a surprising distance,
creanng a large gap. The inexperienced surgeon wil spend t me mobilizing
both ends of the transecied aftory in a herolc effort to bnng them together
This entails add tonal dissection and sacrificing branches atong the way.
Despite these afforts, the resulting end-to end anastomosis will often be
under considerable tension and will have io be redone, this time using an
interposition graft. Therefore, in vascular trauma, the best opiion for
compleie transection of an artery is often an interposition graft,
Transected artery = interposition graft
Patch angioplasty is an optlon to keep in mind, especiatly if at least hatf
the circumference of the artery is still intact or if the vesse is small. We
rarely repair a laceration tn a brachial or popliieal artery wthout a small
vein patch, because even a transverse y oienied latera repaf wi I narrow
the lumen of lhese smal vessels,
Before you begin ihe reparr, pass a
disially, and then flush the vesse with
catheier wlll not only evacuate coi, but
facilitating your repair.
Fogarty catheter proximally and
heparinized saiine. The Fogariy
aso will dilate a spastic vessel,
3 /our voscuro To"rki 
g
Systemic heparin has a bad reputation in vasculaf 
trauma' raising fears
o'clusing U'eea,ng In Ihe adlacent trdumatiTed 
soft {rssue or In remore
'ni, nes. Hlowever, wfren deal:ng wrh an isolat€o arler;al Injury' 
especially il
tir, t"o"', 
" 
n"t"n 
" "ke 
rime' give system c heoajn to protecl Il'e d;stal'microcirculation 
Popliteal ariery repairs are a good example where
sysiemic heparin makes a difference
Oo vou l'ave Io tepair injured veins? lt is a 'urury rol a 
mJsl ll a vein
" 
,. i"*i'"" a co.pre* ,epai' t may not be wonh ine toJble 
These
,J""1t" 
"]" 
t""n"tnrt rno'e derand'ng lhan arte'ial reconsrruclions 
often
*in 
"i"t"i"""J,'i 
*tencv' and mav oe 'nnecessatv lr Ih€ 
palient l'as
.ti* 
"'r""" 
ti" ,"qui," 
"""ntion 
susta neo a srgn lcant physiorogical
'"""rr, 
"ih"]0""" " 
t'" oR {or many houts' ligaie lhe Inlured ve n w'thoul
hesitaton.
l{ vou decid€ Io iaduge i.] a combinod arleria' ard venous 
reparr' lhe
u"nou" ,"con"tru"rio't should come {irsl because a 
thrombosed ven
"""noi 
o" 
"ff".tiu"fy 
cleared R6membef io interpose viable soil tissue
Setween the ve"ous and arieial tepa rs Io nreveni a fislula
Vein repair b a luxury - not a musl
Working with grafts
Choce ol qrah malerrar rs a mapr collroversy n vasculat 
irauma No
.""' ;J";"" 
""t 
a syntherrc lrair oelow ll-e Lnee or drstar Io 
the
"l"rfa.t 
i"""r"",n" *ssels are ioo small; 4mm synihetic 
grafts simPly
a.nii *o*.. ft,i" locuses the controversy on the 
femoral artery The
irooon"nr" ot u"in sr"ft" emphas'ze how wel' Ih€y worK 
altho'lgh Ll'ere is
.n .ooa ev'derce ihat ll_ey do beiter il'al synthet;c 
gra+s ri young
;:;;*';;;"t;"t oufrow trac$ rhe p'oponents ot 
sJnlhet:c sta{is
:;;;; ;; ;" Ihev rarl s nce n Ihe preserce 
ol nleclion and
"; ;" : ; ; . 
. ; ; " sta{ i ;essicates ano.dssolves 
resLr ' t :ns :n sudden
hemorrhaqe. A syrthet c gral t ia i ls gradual 'y 
by lorm ng a
oseudoaneu'Ysm A4oIl'er aovanlage o'1he syllhetc 
graft is €{pedlercy
Lr, 
-o"r"o* 
prelerence rs synthetrc grah lor lemoral artery
TOP KNIfE lhe Art & Crofl of Troumo Surgery
reconstruction. The tfuth is thai i does not matter which materiaiyou use,
as long as you do it well.
Graft proteciion is a cardinal principle in vascLrlar trauma. When
ptanntng your reconstruciion, femember that an interposiiion graft in a
traumatrzed and coniaminated fleld inviios disaster. you have io route the
gratt through a clean fieid or cover it wth wellvascularized sofi tissue.
Graft protection considerations may dictate ihe operaiive sequencel
bowel repairand peri toneal toiet before an abdomlnal vascular
reconsiructron; sofl trssue debrdement before an jnterposition graft in an
Injured extremity. Occastonally, yo! may have to improvise an
unconventronal extra,anatomic route for the graft to avoid either a heaviy
contaminated environment or a large soft irssue defeci,
Vascular traur.a js esseniially the art of deating wiih young arteries that
are sofi, pliable, and easily undergo vasoconstriction. Remember these
rnherent qualrtes when sewing in a gfaft. The technical princip e of driving
the needle always from inside the artery out, so religiously taught in
eleciive vasculaf s!rgery, ls trrelevant in vascular trauma. you won't raise
an rnlimal flap in a healthy artery, 6van if you go lrom outside in. So, work
rn whatever direction is nrosl convenrent, but always have tremendous
respect for the arteral wal, because ii will not forgive bad passage oJ the
needle or jefklng the suture sideways. The trajectory of ihe needle musi
always be perpendicular to the arieral wall.
Do not injure the artery with your vascular instrumenis. pass a Fogarty
catheter only a few cent rneters above and below the injury, and do not
over'inflaie, or you wil denlde the healthy iniima. Close the iaws of a
vascular clamp gently ('only two clicks") so as not io crush the artefy.
A major pilJall with yourg arieries is s/ze mismatch. lt ls easy io insert
too small a graft into a vasoconstricted artery, onty to laier reatize you have
created a boiUeneck that inviies early failure. This is particulafy common
in the aorta and i|ac arteries ofyoung adults. Because the vasoconstricted
aorta will dilate later, make a consctous decsion io select a slightly larger
graft than whai you deem necessary at the moment.
Vascular tr6uma is the art of dealing with healthy aderies
3 Your voscuo,rooLk ll
T H E K E Y P O I N T S
) Bleeding and ischemia are differenl 
piorilies
> Balloon tamponade conirols external bleeding 
in lfans(ron zones
) Know the patieni s ioial trauma burden 
and physrology'
) Align bone befote arierial reconstrucliofl
) Get an angiogfam if the patient is stable
) Do pre-emplive fascioiomy before 
popliieal ariery reparr'
> Know the key anatomical landmarks'
) Get pfoximal conlrol outside the hematoma
) Use an iniralumlnal balloon for problematic 
dlsial control
> De{ine ihe full exient of ihe vascular lnlury
) Gradually develop and optimize your work 
space
) Decide between complex vascular repair 
and damage control
> Ligation is noi an admission of defeai'
) Clear ihe inflow and outflow tracts before 
shunt insertion
) Transected artery = interposition gra{t'
) Vein repair is a luxury - noi a must
t Vascular irauma is the art ol dealing with 
healihy arteries
TOP KNIFE The Art & Croft of Troumo Surgery
Chapter 4
The Crash LaParotomY
Damn the totpedoes, full speed ahead!
Admiral David l. Faragut
In most surgicaltraining programs, you sp€nd much 
time in the OR with
,^-. , ,*" .v in nand. merr irv braslrnq away at 5uay eynrocfes whi le yoLr
i",.1# ,,i"o"rt'""'t op"ns tl^e correct liss're o'anes wilh a r'gl-t-a-gled
"i]-. 
r" 
"""oot""""t 
*cl"r Irp or ar educated {'nqer' pretendlng you a'e
Ii"| ,a" 
""""1t* 
*"t vo- cut ss''e . 
tie trots a'ranse relraclon and-_r.r;e 
oowe, are all parl ol In" tecnrrcdl largudge ol 
ge'e'al sLIgef
A rrauma operarror is _oI an acce'e'ated v€rs'on oI 
the elect've
.r*"irr" it .-tr'r"" 
" 
o tlerell I"cnn cdl langLage a'rd moct rmoortantly'
I i i " r"" trnnd""t ln this chdpler ' we dero'sirale tnFse 
d'{erenccs by
Lilng 
" 
r";irl"t op"t"tlon' exploraiory laparotomy' and translaiing 
lt Into
ifre tleclnicat anguage of traurfa surgery Rapid 
alternations between
"*n-","a" "*-"" t t" 
-a_euvers a.rd rel iculous dlssecton are 
rhe
i" ' . """"" i" i ' i r " , nparolonv l l 's l ike dancing through 
a Iear m ne{ield
*iii. pi.yl"s oOOL/- on vour laptop Get the pictufe?
The oPerative sequence
Every trauma laparotomy follows lhe same methodical' 
pfactLced
operatNe sequence
/"r \,t(" 
.r ^'fib
rr\"€ +,0;;;;1
\ - r-++^-
I Exp ro€ t i on " \ y :
Exposue
Tenporary Bleoding
oeflnitive Repair
Control
oamagsControl
E to, *",r, tnu on & croti of TroL,rno surserv
The key decision in ihis algorithm is the chojce between definitive repair
an0 dan'iage conirol. The earlier you make this decision, the better for ihe
patieni.
Gaining access
Enter the periioneal cavity ihrough a long mid/ine incisron, the Texas
name for which is 'Hey diddle diddte, r ight down the middte., , The tess
stab e the paiient, the fasteryou should dive jn. Take ihe scalpeland make
a bold cut through the skin and subcutaneous t issue. l f you grab the
djaihermy to systematicaily barbeque subcuianeous bleeders In a patient
wilh a systolic pressure of 60, you are probabty in the wrong speciatty and
should consider a career change. The hypotensive traunra patieni is
peripherally vasoconstricted, and you are wasting time orj nonsense oozng
wnile rapid intra-abdominal bleedlng continues unabaied 2cm below the tip
oJ yoLrr diathermy. Sounds pretty st!pid because I |s.
The incision begins below the xiphoid, skrrts around the umbi l icus, and
ends above ihe pubis. An experienced surgeon uses ihree long and
precise passes of the knife to enter the peritoneal cavity. The first sweep
gets you past the skin and into ihe subcutaneous tissue. The second pass
lands you on the liriea alba. Develop the abiliiy to gauge the depih of th€
subcutaneous fat and ihe 'feel" of landing on the fascia witholt cuiting it.
The third and last pass of ihe knife divides ihe linea alba to visualize ihe
prepentonealfat .
4 The Crosh Lopororomy
Tra:n yours" l l to ma^e tne ncisonl:Ke a 
pro l r ' r la(es Yo' l l rve or si \
.*""p". 'yo, a- or.ay O,t not yet ready lo 'prrme 
t ' "e '
The kev -anF.rver .s 10 cul in thF miol :ne whe'e the abdom'nal 
wa' l ic
,n,nn" '" , l lo ""ur 'n,o 
,ne aboome" :s qLlckest Tnis rs cal leo "garnirg 
lhe
",,0i,"".,iO 
n"jr"*" of the midline is the 
decussation oJ the fibers ot
tt" unt.rioir""tu" sheaih lf you see muscle underneath 
your fascial
incision, sieer medially
Now, take advantage oi
a little-known anatomrca
faci. In most Paiients, the
periioneum just cranial to
the umbilicus is either
very thin ot has a delect
There is only very thin =
preperitoneal fat in thrs =-
area, making lt the ideal =
enor for enter i rq the ' - - - - - - -
peritoneal caviiy forca "=.:;==;-2')
the elaboraie dance ='
(often iaught in elective
surgery) of Picklng uP
rh-"-oe; i tone ,m betwee. 'wo parrs o{ p c{ 'p- ard makirg d s 'al l 
n:c\ lo
l"iju-;. 5r-p1 po^e a frrqer irro rl-is oer'tone't defecl 
immedralely dbovF
tf'" u*lifi"u", 
"na 
yo, find yourself in lhe peritoneal cavlty
tlsinq a parr ol l^F€vy scissors crr Ihe pFrfioreu_1 toge'he- 
wrth rhe
-J,n"o or"p"t i to.""r iai ' Lo l l 'e rul l exlent o{ the:ncision 
Use your ron-
i" . i ' "" i , i , "a 'o pusn ine Intesr i lFs oown Io 
prolect tnem tor youl
.i".""i"g 
""i**" 
ldeniiJy the {alciform ligament and divide it between
;;;; ; ;;'; 
"""""" 
to ih" tishi uppet quadrant You fe in the bellv'
ready to Rock n' Roll
ilf,Ih" u"tly 
"itt 
ttr"e sweeps ot the knife and one educated finger
TOP KNIfE The Ad & Croft of Trourno Su€ery
A 7oor.1 of cdlttion
Tl_e.maior_pi l 'a l l our ing a crasr laoarororv is,arrogFnic:njury. The teh
lalerdl lobe or -he l,ver rne srah bowet. ano thF braodF, a.e in j;oparoy n
ihe upper, mjddle, and lower parts of the incisjon, respectiveJy. On a
particularly bad day or if you are especia y gifted, you can jnjufe all rhree
otgans in one bold sweep.
lf the patieni has a pelvic fracture, entering a pelvic hematoma is
generaly considered a bad move. IVake an upper midline incision,
carefully peek into ihe abdomen, and extend your incision downward
below ihe umbi l icus under direct v is ion.
Enlerlng the abdomen through a pfevious laparotomy scar can be time
consumrng and exasperating in a hypoiensivepatient. The safe technique
is io extend the lncision beyond the old scar into virgin teffiiory and enter
the peritoneal cavity where adhesions are tess tikety. Then, oper the otd
scar piecemeal, after making sure that ihe lndersurface s clear and
pushing adhereni loops of bowel out of ihe way. Even if you have
completed your incision without mjshap, you may still face adhesrons of
bowel loops to the anterior abdominal wall. When these adhesions are
dense or mult/pie, you will feel a liitle stupid engaging in careful
adhesiolysis while the anesthesiologist is punrping unii after unji of blood
into your hypotensive patient. ls there a quicker way rn? yes, there is.
A creat ive solut ion in an
abdomen with multiple old scars
would be noi to enier in the
midline, bui make a biiateral
s!bcostal incision (also known
as a Double Kocher or a rooftop
incision). The inclsion i isel f
takes longer to make and close,
but you will more than make up
for il by skirting around the
troublesome midline adhesions.
Stay away from old scars
4 The crosh Loporotomy Il
Once inside the abdomen
When you firsi peek into the open abdomen' all 
you can see is a
"p"gi"ni 
of fo*"f top" swimming in a pool of blood and clols 
Your fLrst
iiloi,ti"" "r" 
to u"t,i"u" temporary hemostasis and evacuate the 
bLood so
yoll can see what is golng on
The key manelver
raw is eviscetation
Rapidly gaiher ihe
smaLl bowel loops
outside ihe abdomen
ioward you (io the
r ight and uP) Don't
just shove laparotomy
pads inio lhe oPen
abdomen wlthout evis'
cerating the bowel, an
act akin to throwing
paper naPkins lnio a
bowel o{ soup - and a
total wasie of iime
Evisceration converts the boody mess
allowing you to see whal you are dorng'
achieve temporafy hemosiasis
inlo a manageable work space,
Rapldly evacuate the blood and
Eviscerate the bowel early
Choose a iemporary hemostaiic iechnique based 
on the mechanism ol
nurv. In or.r ' r l - rat-ma begi, ] w' in empi 'car oacl i , rg 
Hand your assisianl
, 1i"" '**" t" ' to e'eva; l tse abdo-rral wa ' ol eaun 
qLaoralr i - IUrn
". i 
i " . . , "" 
"Oo"-"" 
'aprd'v Begi ' wit ts lne ' ig l ' ' Lpper qJad a,tr bv
.,"1 ' i ] * , , 
"r , 
t*o ou", 'n" ao-" ol the ' rve pJl ng ' ' gentrv loward
;; #; , ; t pac\s over vo ' nano 
a'ove ano iFen oelow Ir e l :ver '
i,""kli" iiont o"'"*," nutter' N'4ove to ihe left and 
put your non-dorninant
n"nJ 
"fou" 
tf'" 
"pf""n' 
pulling it gently loward you' ihen pack over your
TOP KNIFE The Art & Crafi of TroLJma Surgery
reiract ing hand above
the spleen and left lobe
of the iver. Create a
sandwich by packing
medial io the spleen.
lVove to the left paracolic
guiier and then to ihe
pervrs, and pack them,
Al this tinre, the evis-
cerated bowel remains
out of the way. lf blood is
accumulat ing on the
evscerated bowel, the
source is a mesenleric
bleeder. Deal wi ih i t
drrectly. During packing
and whi le your non-
dominant hand is retfactrng and proiecting the liver and spJeen, fee/ for any
obvious injury, and begin planning your approach based on this tactile
Empir ical abdominal packing does fot arrest major arter ia
hemofihage. lt gives yo! time to organize your efiort and divides ihe
peritonealcavity into severaldislinct areas you can explore systematically.
Packlng works wel n blunt t ralma because the most l ikely sources of
hemorrhage are the lver, spleen and mesentery. Bleeding from most solid
organ injur ies can be temporari ly control led with ocal pressure, whi le
mesenteric injuries are immediately apparent in the evlscerated bowel
In penetratrng lrauma, your best bet is to go straight ai the bleeder
Glance into the eviscerated peritoneal cavity to deiermine where the
bleeding is coming from. You will then be able io achieve iafqeted rather
lra. bl:nd rempora.y herosrasis. pac^ a b,eeding sohd orgun o,,
In blunt trauma, begin with empirical packing
4 The Crosh Loporoiomy
contained retroperitoneal hematoma' Manually compress a {reely 
bleeding
u""""i. Ct"rnp 
"."""n,eric 
bleedet some surgeons pack empirically in
penetrating traurna cases, just asthey do in blunttrauma We preierto see
eracily what is bleeding and address it directlr'
i
I
In an exsanguinating Paiieni,
consider compressing ihe aorta.
Manual compression of the
supraceliac aorta through a,ho!e In
the lesser omenlum rs mucn sarcr
and as ef{ective as formal
clamping. Transfer responsibility
for aoriic compression to the righi
hand of your assrsianl
Surveying the battlef ield
Once major bleeding is
temporarily controlled, raPidL)/
explore the abdomen The
ifansverse colon eltends across
the middle of Your incislon, and
its mesentery divides the
peritoneal cavity into two -
visceral compartments The
supramesocolic comParlment
coniains the liver, stomach' and
spleen, The inframesocoLlc
conrpartmert contains the small
bowel, colon, bladder, and
f emale reproduciive organs
In penetrating trauma, eviscerate and go for the bleeder
Systematically explore the peritoneal caviiy. It doesn,t matter where you
begin as long as you maintain a iinear sequence that covers the enlire
conieni of both conrpartments. Thls sequence sholld be rouiine and
reproducible. You learn it in residency and methodically repeat it in
subsequent operations, ln your sleep (and jn courr).
Begin your exploration of the infranresocolic comparrment by tifting ihe
transverse colon cranially and funning the gut irom the ligament of Treitz
down io the rectum (or from the rectum backwards to the ligament of
Treitz).
TOP KNIFE The Art & Croli of Troumo Surgery
Two pairs of hands ,
yours ard your assistant's
' {lp each loop of bowel in
a coordinated fashion to
inspect both sjdes, paying
special attention to ihe
mesentery The posierror
aspect ol the transverse
colon and the hepatic and
splenic flexures are notor-
ious for mrssed njurjes. lf
you rdentjfy a bowel
perioratron, contro the
spillage with a soft bowel
clamp. You typical/y smella colonic perforation b€fore you see it. Remember
to look ai the bladder afd femate reproduciive organs in ihe pelvts.
Pull lhe hansverse colon caudad to explore the supramesocolic
compartmenl. Inspect and palpate the llver and gallbladder, and palpate
ihe fight kidney. Then, inspect the stomach all ihe way up 10 the
esophagogastric (EG)junciion and the duodenum (including whai you can
see of the duodenal loop). To fully visualize the duodenum, you musi do a
Kocher maneuver and take down the ligament of Treiiz. palpale the
convexity of ihe spleen and ihe left kidney. Don,t forget to inspeci both
hemidiaphragms and note any injury, as wetl as whether the diaphragm is
f lat or bulging into the abdomen.
4 The Crosh LopororomY
Next, exPlore ihe
lesser sac. As Your
assistant holds uP the
stomach and transverse
colon, Pul l ing them aPan
to streich the greater
omentum, go to the leti
side of the omentum (it is
typical ly less vascular),
and bluntly Poke a hole in
ii. This allows a good look
ai the posterior wallof lhe
stomach and the body
and tail of lhe pancreas.
So far, you have explored lhe petitoneal cavity- Underneath' 
the
r"t;;"'-ft"";;., a sepa;ate visceral compartment' is still lurking 
in the
Exploring the retroPeritoneum
To get to the relro_
peritoneal siruciures, You
must go behlrd the
intraperitoneal ofgans
Global exPosure ot the
entire retroperitoneum s
lmpossible, so the key
principle is limited
exposure of the relevant
retrope ton-aal siftlcures
by rotating the overlyrng
intraperi toneal organs
medially.
Explore the supramesocolic and inframesocolic compartments
. 
Decide whjch retroperitoneal structure you wjsh to explore, guided by
clinical suspicion that it may be lnjured. your clinica suspicion is based o;
the tralectory of the wounding missije or on the presence of a
retroperiioneal hematoma. For example, any hematoma or blood staininq
arou' ld rhe ouodenat oop mandates mooi, izd- ior ol-he seLond pa|. or t r ;
duodenum and the head of ihe pancreas.penetrating injury to the
ascendrng or descending colon requnes mobitization of ihe enrire injured
side of the colon io examine noi only its posterior wall, but also the
adlacent uretet How can you get the intraperitoneal organs off the
underlying retropefiioneum? By doing a medial visceral roiaiion.
TOP KNIFE lhe Art & CroJt of Troumo Surgery
Lefl6ided rredlalvisceral rotation (Mattox maneuver) .
The east accessible area of the retroperitoneum s the mldljne
supfamesocottc sector, which contains the suprarenal aorta and its
branches. lf you iry to get to the slprarenal aorta direcily from the front,
you will have to transect the stomach and pancreas afd then struggle
through ihe dense connective tissue and nerve plexuses surroundino ihe
aona. The [,4€tio' maneuve. altows yoJ lo ducomo ish rh,s erpo,ure s-p y
by lifting the left-sided abdomiiat viscera off ihe posterior abdominat wail
and rol ing them io the fghi .
Begin by mobi l iz ing the
lower descending colon, as in
a left coleclomy. Pu I the left
colon toward you, ideniify and
incise the white iine of Toldt,
and rapidly mobi l ize the
descending colon from below
toward the splenic f lexure.
Continue your move upward
along ihe same line, which
exiends lateral to the spleen.
Keep rehoperitoneal exploration targeted and limited
4 The Crosh Loparoromy
This move enables You
to roiaie ihe spleen,
pancreas and left kdney
in a media direct ion
toward the midline As
your hand sweeps rrom
below upward and
medially behind the lett-
sided organs, Your Plane
is directly on the muscles
of ihe posterior abdominal
ln most srtuatrons
requir ing this maneuver,
the retroperlioneal hema_
toma wi lL do much of the
dissection for you. As it spreads laterally' the expanding hematoma lifls
the lefi sided ;iscera off ihe posterior abdominal wall, allowing 
you to
perform the maneuver bluntLy and rapidly
An expanding central hematoma does the disseclion for you
You know you are In
the correcl plane as long
as You can feel the
posierior abdominal wal!
agalnst Your f ingediPs
whi le you blunt ly dissect
behind ihe viscera with
your hand. Continue the
medlal rotaiion allthe way
up to the diaPhagmatc
hiatus. You can then cut
the left diaphragmatic
cfus laterally, and bluntly
dissect around the aorta
E ,o, *"nr,n" o,r & crofi or Troumo su,sery
wrth your finger to gain access to the distal ihofacic aoda as high as T6.
This is a quick and easy way to gain proximat aorric coniroi wjihout
openrn9 li.F chest. The comp,eted l\4atior maneuver gives you acLess to
ihe abdominalaorta as wel las most of i ts branches, includino the cel iac
suoF.ior me<entFr.c, re, , ,enat ano tef l i , iac aneries.
ll your target is the ao*a itself or its anterior branches, rotaie the left
kidney with the other left-sided organs. lf you leave the kidney jn place by
deveroprng your ptane anterior io it, you will restrict your access to ihe
anterolateral aspect of the aorta. The left renal vein and artery will be in
your way, and the Jeft ureter witJ be vutnerabte ro injury. However, if your
larget js lhe left kidney or the renal vessels, leave ihe kidnev in olace.
Feel the muscles of the back against your fingertips
When you perform the N4attox maneuver for the firsi iime, you discover
(yet again) a discfepancy beiween neat illusifations and harsh realitv.
Don'i say we didnt wa,1 yor.r. Once you nave cla,nped rhe aor;
proximally, it becomes a pulseless flaccid tube that is difficuh io identjfv in
a large retooeritoneal lemaLoma. To -a1e maflers worse, a tnick laveiof
periaortic tissue separalF5 ihe suprarera, aorla l.o7l your dssectior
plane, and you musi divide it to gain the periaoriic plane. We advise vou
to ga n t,rrs olane ai tne irJrarenal leve,, whe.p it is much easier to toeniifv.
and tnen orocFed uo to rhe sup-arenat aorric segmerr. tr youni
hypoiensive tfauma patients, the aoria is constricted and considefablv
smalef ihan you expecl.
It is not uncommon to injure ihe spleen during a rapid medial visceral
rotaiion, so examine it closely when you have iinished the manelver
Another classic pitfali is avulsion of the left descending lumbar vein while
mobilizing the left kidney. This treacherous vein comes off ihe left reral
vein (LRV) and crosses over the left latera/ aspeci of the aorta
immediaiely below the left renal artery. lf you plar io work on ihe aorta
around the level of ihe left renal vessels, it is a good idea to idenitfy,
ligate, and djvide this lumbar vein to avoid avulsjon durino retraction ofthe
mobilized left kidney.
j i . J l L\,,/ )rA
4 rhe crosh Loporotomv rl
Right-sided medial viscelal lotation "
Perform righl_sided medial visceral rotation in three distinct slaqes'
Each successive stage gives you progressively belter exposure 
ol tne
The first stage is the
classic Kocher maneuver,
where you mobillze lhe
duodenal loop and head
of ihe pancreas ldentify
the duodenum and Incse
ihe posterior Periloneum
immediately laieral io it.
Insinuate Yolrr hand
behind the duodenum
and head of the Pancreas
the right renal hilum Beware of injury
to ihe right gonadal vein as rt eniefs
ihe IVC at ihis level
The second stage of a righi_sided
medial visceral roiation is the
exiended Kocher maneuver, which
gives you wider exposure ol the
retropefitoneum. After completing lhe
Kocher maneuver, carry the incision in
the posterior periioneum in a caudal
direction toward the white line ot
Toldt, immediately lateral lo the nght
colon. Note that this white line is in
to begin lifting thom uP,
anJ c"ontinue'molitizing the duodenal loop fiom the common bib duci
superiorly to the superior mesenleric vein (SN4V) inferiorly The 
hepatc
ttexure overlies the lower part of the duodenal loop' and you may have to
mobillze it too Now you can tefleci ihe duodenal loop and head 
of the
oancreas medially to see the IVC and
E ,o, *",rr rnu on & crofj of Troumo susery
;:|,.ff"",dt:irlHr;::##:"ffiil1^i"..iixili"iii;;Til:ifln: :",;"T:::;: ;i;,il;l: *::i:"'"'",'" "n.,'*iiJ,
_^ll: ]n|:O 
stage is, you guessed it, a super.exiended Kocher
Fri:{,ili:iiJi:,ili"]ii:",1""#,3":iJH::H'*:":r"iilt
i:ri:[:]r, iffi ::"."#::t,ff i l;;l;i*m*iri ;
;:'il1;:iT".li";;"'"rero' c'ania'rv aro obJq*'v r'o'' rn. "*u- J
To perfom the Catiell_Braasch
maneuve( do an extended Kocher
maneuver; ihen, carry ihe incision
in the posterior periioneum around
the cecum. Now, gather the small
bowel 10 the rjght and craaiallv,
and incise the tine of fusion of th;
small boweJ mesentery to ihe
posterior peritoneum from ihe
medial side of the cecum to ihe
ligament of Treitz, a surprisjnolv
short distance. you shoutd nowie
able to brjng the small boweJ and
flgnl coton out of the abdonren
and swing them upward onio the
ameaor drest, a pretty remarkabje
srght.
---]h:--C.n:,tp*i*h 
maneuver begins ar ihe common br/e duci (CBD)ano ends at the ligament of Treiiz. Whenp-anoramic vrew or rie e",''." r,,"."""""i" ,"1i#0"',"J"'L,l rJl"rt":::":
to the infrarenal aorta and lVC, as wellas both renat arrefles and veins andthe rliac vessels on both sjdes. ll also provides access tothe third andfourih
Do a risht.sided mediar ni"""J .IiIiIIiIt"-!"!
4 rhe crosh Loparolomy 
g
parts of the duodenum ano the
superior mesenteric vessels lt is
an awesome exposure we
stfongly recommend that You
carefully siudy, understand' and
memorize ii because il is ihe key
to approaching some of the most
diff icult abdominal iniuries.
The maior Pitiall with tight-
sided medial visceral rotatron rs
injury to ihe SMV at ihe root ol
the mesentery. Once You detach
the f ight colon from i ts
peri toneal at tachnreni, i i is
hanging bY its mesentety aone.
An inadvertent Pull will avulse
the dght colic vein off the SMV
resuliing in unexPected bleedlng
from the root of the mesenterY
The Cattell-Braasch maneuver: from CBD to ligament of Treitz
Selecting an oPetative Profile
Now it is time to decide which operaiive pfoflle is appfopriale for 
your
paiientr de{initive repalr ot danrage conirol (Chaptef 1)'Iniury Patterns Indicating the Need for Bail Out
Combined major vascular and hollow visceral injuries
Penettating injury to the 
'surgical soul' (Chaptet 8)
High-grade I iver injury
Pelvic lraciure witf an e{pardrng peivic l^e-aloma
lnjuries requiring surgety in other cavities (chest' head' neck]
E ,o, *",rr rn. orr & croft ol Troumo su.ger1,
Temporary abdominal closure
*rh:]: "i:[iF:';Hig :":T:fl;, :::l?"5ffi :'ilr;f""il ff H:ff "i::;:i;:::' Jiil:i,iliti"' *"";;.;;il;"i ;
::i'f:":it!.i,qii"i,:"_'ii"*r#:,::ft li Jij:i:-;,":;; :t:provtdes a means fof collecting jnira-abdomi
creaies a physicar banier beti,een ffiJfl j:l,i#:ijT:iii:i!;jl
mass. This barrier prevents adhesion formatiof beiween ,f," l"*",1"j
f.#"i:,:JI** 
ihe window of opporiunity ro, 
"",ry a.riniiv"
The vacuum pack is
essent ial ty a sandwich.
The first layer is a wide
polyethylene sheei ihat
you spread over the
abdominal v iscera and
carefully tuck between the
bowel and the abdominal
wal l . Pui two surgjcai
towels over i t , p laced
securely beneath ihe
abdominal wal l on al l
srdes. This is the middle
rayer ot the sandwich afd
iis pufpose is to absorb
contain and protect the uo*"r *t*, t"iplilfiI--inJlfii
4 The croih toporoiomy 
g
Now, Place iwo silicone drarns on
the towels and br ing them oui
ihrough separate stab incisions
Cover the wound with a wide sienle
polyest€r drape, comPleting .lhe
upper layer o{ lhe sandwrcn'
Connect the suction tubing to a Y_
connector, then to a suclion source,
Occasionally we sull use a soti
empty intravenous f luid bag fof
iemporary abdominal closure The
bag is unfolded bY
cut i ing the seam and
then ster i l ized. We
suiure il to the skin along
the edge of the wound
with a running heavy
monofi lamenl sulufe,
preserving the fascia lor
the definitive closufe
This technique is more
tima-consuming than ihe
vacuum pack but provdes
inexpensive, alraumatic
containment of the abd_
There isn t much we can tell you thal you don'l akeady 
know about
definitive closure of a midline lapatotomy incision The correct 
technque
Jrut ino Uiq oire" c 'ote rog€thFr, withoLi tersron We do a 
tass closure
'" , i i "v""," , i " ns . . - i19 heavy mo'rof i '?mert 
sutJ 'F' beoirnrrg ai both
""a" "t 
tn" i""i"i." and working toward the middle The cardinal sin 
s
"i"""* ""0", 
tension lf you siruggle lo contain bulging or distended
uo*"t, ,f'" outi"n, 
"iff 
f" ;uch betler off with temporary closure l/lake a
4 rorrrn,*^._ ,* 44 8 Crol t oI i ,outo Surger/
iihtil*r,",31 il'r".ffi :,T:iT,,H,",:".""","rx-q;
T H E K E Y P O I N T S
) Enter ihe belJy wjth thfee sweeps ofi
) siay away from ord 
"""r". 
'--- '' 'n" nn^ 
"nd 
one educated finger
) Evisceraie ihe boweteariy.
) In blunt trauma, begin with empirical packrng.
) In penehating trauma, eviscerate and
) Exprore rhe supram""""",::* 
,;,; 
t" t"r the bleede'
) Keepretroperitone",",r,:.;;,.,r;":::;J-*-.
) An expanding ceniral hemaioma does
) Feer rhe muscres o,,r" ;";";;*, ,:";. 
t""""
) Do a rjght-sided medial visceral rotatjon in three stages.
) The Caiiell_Braasch maneuveri from CE
) conian and prorec,,,," ;;:; ;; ;;,:";ffi_:"_"
ChaPter 5
Fixins Tubes:The Hollow Organs
And if anvthing lhal I saV should bear lhe apPeanncP 
of
)-",'"r17ii'rt?r*u, let ie publicly cont'ess that Ihi5 book
li"i""riti, 1r"* a sonooful coniemPlalion of 
the 'nonv''rigiroi 
,nort ,nirn I ha;e myself conmitted
- Harold Burlows, CBE
Erlalls o/S /ge'Y' 2nd ldition'
London' Bailliere' Tindall arld Cox' 1925
One of the mosi remarkabLe 
'corrective experiences' in surglcal
training comes during the morbidity and mortality conference' 
as you
relucta'ntlv rise io explain to an unsympaihetic audience 
how you
overlook;d that bullet hole in the duodenum From our own expenencer 
no
Jrir"" 
"or"a" 
p"tti""r"rly convincing' so never get loo complacent wth
ihe injured gut lt often hides some nasty traps'
Immediate concerns
Your l i 's 'pr 'o ' i ies are Io conl ro lo leed'ng and conla i l 
sp l l lage o ' '1 lest 'na l
-"*t 
", 
,i:"" ff'" **e' does 1oi bleed mJcn bJ'the 
mesertery does
lf the bleeding vessel has
retracted beiween lhe
leaves of the mesentery'
all you can see is an
expanding mesentenc
hemaioma. Raiher than
waste irme ttyrng Io
ideni i fy the bleeder,
simply apply Pressure Io
lhe area, We usually use
either the assistant s
hand or long sPonge_
holding {orceps aPpl leo
TOP KNIfE The Art 8 Crofi of Trourno Surgery
to ihe injured mesenteric segment, squeezing it gently between the ringed
When the bleeding lacefation is close to the root of the mesentery
beware of a irap. Never junrp in and bllndly clamp or oversew ihe bleeder
because you rnay destroy a superiof mesenteric vesselor one of its maior
branches. A classic example is blunt avulsion of a proxinral branch of ihe
SMV which can be the result ol a deceleration injury or iatrogenic irauma
lrom puiling hard on the mobilized right colon. you encoufter bnsk venous
bleeding or a rapidly expanding hemaloma at the base of the mesentery
Blind clamping may result in a transected and ligated SIVV
The correct approach is to
insinuate your hand behird the
mesentery and pinch the
bleeding area beiween thumb
and forefinger. This controls the
bleedrng. Now, carefully oper
the serosa, precisely define the
injury and fix it. With a bllnt
avulsron injury, you will have to
f ix a side-hole in the SMV
Use soft bow6l clamps to
control spillage from stomach or
bowel perforations. A hole in the
stonrach or bowel can also be
temporarily whip-stltched wlth
several bjg bites that will control
mucosal bleeding. Pack a
bladder perforation f or lempof ary
Bleeding from the root of the mesentery is a trap
Missed injuries
Pay special atiention to five locaiions where
often miss a hole ln the gu:
5 Fll ng TLJbes: The Holow o'nt* H
cursory insPection will
tuophagogast c Lbament or
Tleits
Mrssing a gastr;c Perfora'ior has me 
'nosl immeoiate coiseorerces'
ci""" rL". qtomarh is tne 'nost vascLlar organ ol tne gLlt 
-lssing a I'ole
i""""- t" , * i f ' be bacl in l l^e oR wthin a 
coLple o{ hours rac'ng a
Hil;;" ;" ; 
" 
*atermelon filled with blood and clois Much like 
a
;i;"J;; ;;; ;";" the mosi 
problematic and easilv missed sastdc
iniuries are located high on the lesser curve or 
in ihe posterior wall near
111'; ;il ;;;t;" t"h" s'"ut"' ""u' 
or the stomach bv dividins the
o""t."ofi. o."*rt. Ope; the lesser sac widely 
and lifi ihe greater curve
;p to have a good look at the entire Posierior 
wall'
TOP KNIFE The Ari & Croft of Troumo Surgery
ln addition to a very meiiculous exploration routine (Chapter 4), two
saleguards help you to avoid missing a hidden jnjury to the Gl ?aci:
1. Reconstruct the trajectory of the wounding agent. Thrs tmjectory must
oe trnear and make sense. Bultets and knife btades do noi disappear
inio thin air on/y to feappear out of nowhere in another part of the
abdomen. You musl be able to connect the dots. When the trajectory
oi ihe wounding missile is unclear or does not make sense, you
probably are missrng an injury.
2. Be concerned when f inding an odd nlnrber of holes in ihe gut.
Tangeni ial wounds certainly occur, and occasional ly a mis; i le
pedorates only one wall, but this is uncommon. Therefore, an odd
n!mber of holes should prompi you to re-evaluate the area in search
ol a missed pedoraiion. The oniy exception is a single stab wound to
the anterior gastnc wa I, which is relatively comrnon.
When examining the colon, it pays to be relen|essly paranoid. Because
nruch of the colon is reiroperitoneal or covered with omentum and
pericolic fat, missing a small colonic perforaiion is easier than yoLr ihiik.
Do not leave any subserosal hematoma on ihe colon, no maiier how smali
and rnnocent-looking, without unroofing it by opening the overlying
peritoneunr. Very often, this seemingly lnnocent superficial siaining hides
a perforation. lf the wo!nding agent passed close to the right or left coton,
mobilizeit and look carefully at ihe posterior wat.
The ureter, 1oo, cafries a high rate of missed ifjuries. Whenever a bullei
irajeciory passes afywhere near a ureier, nrobilize the re evani side of the
colon, identify the ureter, and irace ii proximally and drstally io ensure it is
intact. Iniravenous methylene blue dye helps identify a ureteral injury that
rs not rmmed aiely obvlous.
Bullet traiectories are linear and must make sense
5 Fr, lng Tubes The Holow Orgo's n
Choosing a repail technique
Now that yoJ are 'eaoy to repair Ihe ;nlutle5 
choose an ooeralive prof e
r:r*il :"1i1*:::':il"d1," 3:l ::1"x1;;,:';li J:'l ::ffilll';"::,*:;' ;r;:* ru :x'i:!J:,'il""i:'" ":"'il;"' :i ;"'i;
;"-;;'iai";;i;o;-"sorLi'ons YoL don\ l've Io 
do a ro-mal 'esecton
and reconstruction to prevent spillage'
Damage control fot the bowel
The most €xpeditious way to prevent spillage {rom a eeforillon-(11-d-l:
uchi"ve lemostusjs at tne same time) is to rapidly *t*t ]:,i:'iS-:^:19-:' ' 
t"a' -taP el Whel operat ng
,ayer contin,oLs stilcl' or' less common 
y a lr'.,
;';;;;; ;;",;;.;''however, there are ofte" ll|]*"1-1""^llllill
ff i .;:1."ti;; ;; ard the parent's phvs'orosv, ard 
-assourarFd
i": i" il"""i",r.- il ro oarieri,y p€rcn up.hor" i-,::]ill"]lljllt",ile 'e ar€ tnF most common'Yq;:c^ ard ef€cllvF spi"age conLrol so uton t
used opiions:
a Bowel interruptlon oY
stapling across wfln a
linear siapler Pfoxmal ano
distal to the Perforated
segment, or ligating ihe
bowel using a cotion laPe
wiihout reseci|on
a Bowel resection without
anasiomosis is a good
solution if ihe injury involves
a bleeding mesentery ll
you have to resect a
considerable lengih ol
bowel in a Patrenl /n
exfremis, Your qulcKesl
option is to sequentially fire
a series of linear cutting
siaPLers with vascular
E ,o, *"n, rn" o,t & crcrft oi Troumo suroerv
loads across the mesentery close io the bowel wall. lf residual oozing
f.o- rhe craole. hae oersists, raordly underrun,t wrtr a cont,r-oui
monot tamenl stilch
a Stapled partial gastlc resection without reconstruction for a
devastairng gastric inlury is a third opiion. This stapted emergefcy
gastreciomy is a staged procedure - wiih resection during the initial
bail oli laparotomy and reconstruciion at laier reoperation.
During a bail oui laparotomy, avoid external stomas, if possib/e. The
abdominal wall swel/s up postoperatively, and ihe stoma often retracts or
becomes ischemic. By cfeatiig a stoma you afe also makifg definiiive
abdominal closure more difficuli.
Ulological damage control
Ur ne spillage into ihe periioneal cav ty caffies a much lower short_term
nsk of infection than intesiinal spillage. If time is critical and you need to
get out of the abdomen, tle off a transected ureter and plan a
percutaneous nephrostomy if the patjent survives. lf you have no time to
fepair an injured bladder, just pack ii and rety on a Fotey catheter for
drarnage - a suboptirnal bul accepiable solution if extreme circu..stances.
It you have a few minuies, intubate the tnjured or transected ureter
proximally using any available ihin caiheter (such as a pediatric feeding
tube). Secure ihe ureter to ihis drajn with a tie and exierlorize ihe drai;
through the abdominal wall. Leave the distal ureter alone. It will not leak.
The biggest m stake yo! can make with a ureteral injury ls io mobilize
and dissect oui the ureter in an attempi to better define the injury. you will
only jeopardize the blood suppty of the njured ureter and make
subsequefi reconstructron more difficult. lf you afe noi going to repair it,
lust divert the urine and don t fjddle with the Lrreter.
You can conhol spillage ffom the injured gut without resection
5 Fixing Tubes:The Hollow Orgons f
Close a bladder iniury with a quick running 
stitch lt doesn't have to be
" 
r."'"ni"1l","a 
"t.a-*pair 
if you are pressed {or time: a single layer wrll
^^ ' " ;." Wfit" a'wavs tne 
besl oot;on' sLture closure 
iay loi be
L"j o," r"'ir u u"'v ,"tn" delecl On rhose'are oLcasions 
vou 'nav eecr
,ffi.ri lt *tr#r"J roih ureters and iightlv packing 
the open bladder
{or hemosiasis
Def inifive lePair techniques
The stofiach arrd distal esophagr'rs
Reoair qaslt'c perforations Js:ng a 5ut'i'e or slaoler' 
On ra"e occa"'ons
massrve o;skJcl:on ol the stomauh rcqJires d 
panial gasirecto-y
The cardia is ihe pari of ihe stomach most difficult to 
visualize and
repair, especially in obese patients Approach these 
problematrc Inlurles
svstemarrcdly. Frrs ' , opirmire your exposu-e l - lh6 ncison 
ene'rdrng as
f j , , " 
" . 
o" i" iUf"f ," r" ' r ' -Fi ;ac1or do ng urelJl work? SnoJrd vouinseri
." ,lp* i""l i"u*t,irr lslhe patient iilted head uP? Nen' 
mobilize the EG
jlnction as il You wete gorng
to do a vagotomy We do
realize this is rapidlY becoming
a losi ad, but in this situation ii
is the key maneuver' Take
down the lef t i r iangular
ligameni oJ the liver, told uP
the left laieral lob6, oPen the
posterior Peritoneum overlYrng
the esophagus along the
'white l lne, ' and encircle the
esophagus wlth Your nnger
This gives you good access Io
the injuri,.
i-,"i*n" it 
"n "t""tt.nt 
damage control option for the ureter
TOP KNIFE ]he Art & Croft of Troumo Surgery
Someijmes you have to develop a creative technical solution for a
proximaJ gastric injury. Jf you cannot roli ihe distal esophagus and cardra
io expose the injLrry because it is posterior, open the anterior wall of the
stomach longitudinally near ihe cardia, ihen jderiify and repair ihe hjgh
postenor perforation from within ih€ siomach.
Injur ies to the disial (abdominat) esophagus require the same
mobilization of the EG junction and care{u definition ofthe lnjury.lfyou are
operating jn damage control mode and there is no trme for meiicuous
dissection ard repair, insert a large suctior drain into ihe open esophagus
and bring it out thfough the abdomifal wall, creating a controlled listu a.
This effect ive temporary sout ion eaves ihe door open for later
We repair a slmple laceration of the distal esophagus using a single
layer suture after careful debridemeni of the pedoration, and we always
drain the area. You can use the cardia of the sromacn as a serosat palch
(Thals paich) to buttress the repair. Very rarely, you wlll encolnter a
devastaiing lnjury that has destroyed the EG juncrion and requires
resection of the distal esophagus and proximal stomach - a proxrmal
gastreciomy. These patients typically have multiple assocrated injuries and
need a rapid bail oui solution. Transeci ihe siomach across the body using
a lrnear stapler, preservlng as much drstal stomach as posslble. Lift ihe
prox mal part of the inlured stomach and mob lize lt along the lesser and
grearer curves atl the way up to ihe esophagus. Divide the nrobillzed
esophagus as low as possjbie and remove ihe destroyed part of ihe
proximal stomach. Secure the open esophageal stump to the diaphragm
to prevent retraction into the chest, and insert a closed suclion drain inio
the lumen. This danrage conlrol solution leaves the pateni with a stapled
distal gasiric remnant and a dfained open esophageal stump.
Access proximal gashic injuries by mobilizing the EG iunction
5 Flxlng TLJbesr The Holow O'gt* E|
The small bowel
Before repairing a hole in the small boweL make sure the 
edges ol lhe
p"*or"tion ur" hJafthy and oozing nicely- If ihe bowel wall 
is bluish or
iraumatizeo, debride it. This is especially important wiih 
high-velocty
"rnlnoi*ou"a" 
*1"t" tissue damage around the hole can be extensive
Lornrnon 
""n"" 
dictates repair oJ bowel perforations in a transverse
o--ri""i"tl.n, *ti'"t tf,"" fongitudlnally, io avoid narrowing the lumen 
Joining
".L"".iia". 
i"'o 
" "nsle-'acerar'or 
* rl save you lrme a,rd Lrouore Ho es
ln'*" n'","t"n" bo,Jer or the bowe can oe t ' ic\y 
'o f i^ CatefJrly
mobilize the adiacent mesentery to see ihe entire defect clearly 
before you
begin sewing.
Expect some difficulty wiih iniudes io the most proximal 
jejunal segment**'iJii" o"t"" "f 
r'eitz T;e kev is io mobilize ihe ligament and free
if'"-frorinra"ppnrrrl Rarely' you may have io do a complete 
Cattell'
era.""L man"uuel. (Chapter 4) to get to the foudh portion 
ol the
duodenum and iis transitlon inlo the proximaljejunum
Repai ' Ihe bowel Lsi ,rg ILe tFchnroLre yoL a e -osl co- lortable 
wi 'h '
O_e ol u- p 'e{ers to use o si_g e taye'corr i ruous st tc,r ror mosl 
Gl sul ' r 'e
lines (including the stomach)' while the other prefers a double 
layer
techn'qLe. Bot,l a'p sale 'r perfo'meo corr"uJv 
-esLhng i,r a.l irvered
*el l .vasculanzeo sLLUre ire wi l l^oLl 
-ension l f yoL n^us' do a bowe'
fesection, preserve bowel length and minimize the number of sulure 
lLnes
Tne lpwe'suiLre l ines you creale 
rhe befte '
Colon tt til rcctum
lf vou can close the 6olon Lacetaiion with a simple sr'riure 
_ jusl do ii No
amo;nt of peitoneal contamination should dissuade 
you ffom doLng a
straightfoMard prinrary repair' Blt what if ihe injured colonlc 
segment
mLrst be resecied?
Preserue bowel lenglh and keep suture lines to a minimum
For a right-sided or transverse coton injury, the answer is simpte: do a
right coiectomy afd join the terminal ileum to the iransverse colon. This
sate anastomosis is unlikely to cause you gref. The question becomes
more interesiing (and more controversial) in the left colon. your options are
io do a colocolostomy or to close the drstal colon as a Harlman,s pouch,
bringing out the proximal segment as a colostomy. An extended righi
colectomy and rleocolostomy in ihe descending color is a va id alternative,
bul t is se,dom Lsed in -raL-a becaJse I is t tme-consum n9.
In recent years, resecting and joining ihe unprepared left co/on has
become a iashionable opiion. I\,4any surgeons ialk about ii;fewer do it, and
some have had occasion to regrei it. We belong to the lafier group. Our
preference for extensive Ieft colon damage is resection and colostomy. We
may occasionally do a co ocolostomy for an isolated colon injury in ayoung
stable paiieni who can toleraie a ieak. We would not even contemo aie lt
i , r a oal,e,r t who ha- sJsr€r leo massive prys otogiua rrsJl t , rs eldel v dnd
f.ai , . of Lnde.went oihe. -epairs t l -at mav lea\. A case in ponl i ; the
exp osive combination of left colon and left kidney repairc, where a leak
from one suture line puts the olher repair ln immediate jeopardy.
1 .
TOP KNITE The Ad & Croft oi Troumo SLrrgery
Try to identify ihe injury using a rigid procioscope. Repair it only if tt is
easrly accesstble. lf you suspeci a rectal rnjury but canrot prove it,
perlorm an enrpirical fecal diversion. A temporary colostomy is a
nuisancei a missed lower rectal injury can be iatat.
Do a slgmoid loop colostomy. When properly construcied at skin-
level, ii is totaly diverilng. Some surgeons use a linear stapler to ctose
the coion immediately distaito the colostomy, oryou can sjrnply iie the
sigmoid wiih a heavy polypropylene suture and anchor the stitch to
ihe fascia.
lMany surgeons talk about colocolostomy for lrauma; fewer do it
Deal with an niury to the intrapeftoneal rectum exactly as you would
handle a peforaied lef t colon. Management oJ trauma to the
extfaperilonea recium used io be an elaborate ritual ihat lnclLrded iotal
diversion, repair of the injury, washout of the distat reciat stump, and pre-
sacral drainage. The current approach is much slmpler:
2.
5 Fjxlng TLrbes: Ihe Holow Orgo"s 
g
don't insert a Presacral draln'
Bladder and wetet inities
Here, we can summarize our advice in a single word: DON'TL 
When
oos"ifL. ast u urofogi"t to perform definiiive repair of an injured 
bladder
lr ureie. The ,-rrotogist las a beiter grasp of the various technical 
opiions
""J 
f]o* to 
"loo*in" 
fest one for a specific situation Furthermote' the
ufolooist will also manage any complicaiions and underiake 
long'term
folrowl-rp. Wheneve. pocsibe. we aol^ere Io tnis onnc 
pre even wrlh
straiohtlo'ward illtapethoneal badde' njuries li a Jto'og st 
is nol
avail;ble, damage conirol is always a sound option
3, Don'i irrigale the rectal stump
Neither is necessary'
T H E K E Y P O I N T S
) Bleeding from the root of the mesentefy is a trap
) Bullet traiectories are linear and must make sense
) You can control spillage ffom ihe irjured 
gui wilhoui reseciion
> Drainage is an excellent damage conttol oplion 
for the ureier'
) Access proximal gastric injuries by mobilizing the 
EG junctron'
) Preserve bowel length and keep suture 
lines lo a minimum'
> Many surgeons ialk about colocolostomy for trauma; 
fewer do it'
) Dlved the fecal stteam away from extfaperitoneal 
rectal injuries'
6IJ tn"-"* tn" t"*t 
"tr""t 
away from extrape toneal recial inluries
P ,o, *n,rr rn. on & cfofr of Troumo sursery
a.npoa,tt aa$ "49{ J
* ^"- ^B carry'u'67 -
- r^'v')
' /1,-0 \r,
----.-\
?'.ct<1 t{*: o .L\}-,**G4-.
I
#-
&r'- o- t,.t".tzl-}\ g,tt 4'z r*7*l< -
&,t.- s-x-
uJ^rr^ d r-*.4
V
(1fnt
Chapter 6
The Iniured Liver: Ninja Master
No battle plafl s roioes the first fiae
fiill tes oI cofttttct Toith the eflefi!'
- Field Marshal Helmuth von Moltke
l{ trauma surgery is a contact spori, lhe badly iniuted liver is the 
Ninja
Master: a vicious, cunning and lethal adversafy When you come 
lace_lo_
face with a massively bleedlng llver' gLance ai ihe OR clock and then 
atthe
anesthesiology team frantically pouring blood products into 
a raprd
;nt,rsion d"UJe you huve a window of aboul 20 minutes and roughly 
8-10
units of bLood io slop the bleedlng That's all Take much longer' lose 
more
i i"oO, ot." t" an error ln iudgrient or iechnique' and ihe Ninja 
N4aster
wins again
Obtain temporary control of bleeding
Once inside the abdomen, quickly look al the undersurface of th€ 
lver
and swipe your hand over ihe superior hepaiic sLldace on boih sides 
ol
ihe falciiorm llgameni lflhete ls a signiflcant liver injury' you willsee or 
leel
ii. At ihis point ii is tempting to start fixing the iniury 
- don tl An obvious
lwer injury is often jusl one of several sources of hemorrhage 
and noi
necessarily the mosi important one Resist your natural tendency to 
zoom
ln on the bleeding liver as yout pdme iarget befofe rapidly assessing 
the
rest of the abdomen
Your fLrst priority wiih a bleeding liler is to stop ihe bleeding The three
ootions {of ter.porary control are manual compression' temporary
packing, and ihe Pringle maneuver Each option is useful for specifrc
operative cLrcumslances
TOP KNIFE The Art & Croft of TroLrmo Surgery
a Have your asslstant reach across ihe operaUng ta6te and nanualy
compress the injured lobe behir'een the palms of both hands, an
excerrent way to gajn temporary conlrol of a badly shaiiered lobe. li
also allows you to begin hepatic mobilization around the compressing
hands.
) Tenporaty packing ts a good rnriral move, especrally tf you are not
sure if the liver is the major source of bteedtng. Rapidty compress the
lnjufed lobe in a sandwrch of laparotomy packs placed above and
below it (Chapter 2). You wit return shorily for a ctoser took and
def initive hemostasis.
a l i the iver is bleeding
despite temporary packing,
consider inflow occlusion
of ihe portal triad, the well-
known Pringle maneuver.
Poke a ho/e in afr avasculaf
port ion of the lesser
omentum to ihe left of the
porial t f iad, inseri an
educated f tnger into the
esser sac, and gently pinch
the portal tlad between
th!mb and Jorefinger. lf the
maneuver is working and
bleedrng stops, replace
your ingers with a large
aortc vascuar clamp, a Rummet tourniquet, or ( i f none of these s
immediaiely available) a soft non-crushing bowel clamp. Note ihe
tme. Nobody knows for sure how lofg the porial triad of a trauma
paiient can remain clamped before ischemic damage occurs, but you
have at least 30-45 mlnutes, probably more. Rer.ove ihe clamp as
quickly as you can.
Sometimes your temporary hemostaiic maneuver fails and the bleeding
continues. Barring a techncal error (suchas neffective packing or an
6Ihe lnjured Lver r inl" v" ' t" ' I l
incorrectly performed Prlngle maneuver), there are ihree 
posslbe reasons
Jor ongoing hemorfhage:
a Packs oo 1ol conlrol ane'al b eeoilg You reeo 'ntlow 
occlus:on
a lf the bleeding lrom lhe liver looks aderial despite inilow 
occlusron'
ihe hepaiic ;ery may have an anomalous origin Try supracellac
aodic clamPing
a lf dark blood i; gushing from the deep recesses behind 
ihe liver' you
are aeatlng *iih'a rei;hepatic venous injury lf you aren'i sufe' 
ask
ilJ 
"n""tf'"""iofosi"t 
to momentatily disconnect the paiient from ih€
1 vent lalo- l{ tne b,eeoing abares' your s'rspicron is uonf'r ed 
and yoJ
- ,no 
"or. 
panent are i; dt;FlroLb'€ lncise lhe lalc;for- ligameni'
g"-' i, *i ' i 
" 
a"-p ald oush s"rirv Posr"rio' ' ' i l : t: 
' ' i , ,:1 *::
ilts tne rv"r ba'kward end may lemporarily "ortrolil'e 
bleedlng wn |e
yol.r colsioer your oprio,rs and orgarrTe yoJr attaLk
Mobilize the iniured lobe
Unless ihe hepatic
laceraiion is Peripheral and
anterior, you cannot assess or
fepair it until You have
delivered the injured lobe to
the midline, much like the
injured spleen. To mobilize the
left lobe, divide the iaLciform
ligameni between clamPs and
then release rt all the way uP
to ihe diaPhragm, exposLng
the areolar tissue of ihe bare
area of the liver Then divide
the left triangular ligament
and conUnue the incision inio
the anterior and Posterior
coronary ligamenis Beware
of the Phrenic vein that is
very close to your scissors
Controlthe liver temporarily uging hand, pack' or clamp
TOP KNIFE The Arl & Croft ofTroumo Surgery
S r.ilarly, puttlng your hand
behrnd the r ight iobe and
rotating jt medialjy streiches
the right triangular ligament
and allows you to divide it
safely. Cont inue the mobi l
izat iof by releasing the
anter or corofary l igament
(taking care not to inlure the
lver capsule or the r ight
draphragm) and then the
posterior coronary ligameni.
Your goal is to deliver the
eftire rrghi lobe io the midline.
Be liberalwith your mobilization, but atso be carefuli the hepatic verns
and IVC are wa,t .rg tor a carele5s move, ano tre smal, acce;so-y ve 1s
eniering the IVC below the right hepatic vein are easrly avulsed with a
Mobilize the injured lobe to deal with it face-to-face
Here, a deadly pitfall awaiis you. N4assive gushes of dark blood comrng
through a deep iaceraton n the liver or from behind it ik_"ly represeni an
njury to ihe retrohepatic veins. Mobiizing the liver in ihis situation is a
recipe for disaster You wil lose containment, and the patient wil
exsanguinate from uncontrolled venous hemorrhage before you even
realize your mistake. So, ifyou have any suspicion of a retrohepatic venous
injury, don t mobilize the liver
Small problem or BIG TROUBLE?
Nowhere s the disl inct ion between smal l probtems and Btc TROUBLE
(Chapter 2) more usefulthaf in hepatic irauma. Small problems are liver
Inlunes that you can fix wiih a direct, srmple maneuver: the diathermy, a
liver stiich, or a loca hemostatic agent. The injury is accessible and bLood
loss is noi dramatic. Most liver injuries belong in this category.
6 rhe lntured Lrver' Ninlo Moster 
g
BIG TROUBLE is a high-gtade iniury with massive blood 
loss' and you
*"'i" it.i"""ia*g"t i lJsing your patient The decision 
whether lhe
ii,y i" 
" "."rr 
ptoSL. or BIG TROUBLE is the kev stategic decision in
hepatrc lrauma
Deal with low_grade injuries directly lf a superficia laceration 
is not
of"eJlnq, f"au" it lrone l{ ihere is slow oozing, direct pressure for 
a lew
t""i."".U"" stops the bleeding Your hemostatic effods should 
be
proportionalto the magnitude of the injury (Chapier 2)
With deePer laceraiions'
have your assistant Pinch
ihe edges of the laceration,
turn the cautery to KILL,
and blast the faw bleeding
sudace, focusing on the
disruPied edges of the
hepaiic caPsule APP|Y ihe
cautery to a metal sucker
l ip to achieve a wider
effect. Use an Argon Beam
Coagulaior, i{ available, to
thoroughlY barbeque ihe
raw surface. Use a toplcal
hemostailc agent You are
Jamiliar with from electve
surgery. ,- 
tJ-' t
Nevi, consrder hepdlorrhap'ly For yoLr sJlLres Io holo you 
need a
,"""onufty int""t ""p*te 
ani a more or less Linear lacefalion that can be
"_o-otlt"t"a 
sidelo_side We typlcally suiure hepatic laceraiions with 0
.iiornl" on 
" 
utrnt-iip Lurge needle, cfeatlng a row of horizonial maitress
sutures. The chromic suture slides through the hepatlc 
parenchyma' ano
ihe laroe curved needle enables you to obtain a good bite ot 
irssue
TOP KNTFE The Ari & Croft of Troumo Surgery
, 
Wrrh Blc TROUBLE, you are ope.ar ing . . l damage controt rnode. Ihe
Key lo sLccess ts yorr ability -o srop the ooFraltol a1o o.ga'lize yoLl
attack on the injury rather than get canied away and attempi h;rorc
maneuvers on an exsanguinating patient {Chapter 2). The rest of thig
chapter describes ihe techniques we have found most lseful in baifles
wilh hepatic Blc TROUBLE.
"Packing plus,,
Packing is the technique you will use most commonJy for a high-grade
|ver injury. lf you have packed the liver early as a temporary hemostatic
maneuver and the bleeding has stopped, you have achieved homostasis.
Removing packs at this point is a mistake.
When you cannot be sure thai you have complete hemostasis wth
packing, especially jf you had to remove the packs for bleeding bui did noi
find any discrete arte al bleedefs, considet packing p/us - imrnediate
postoperative angiography with selective embolizalion as a hemostatic
adjunct. Thjs is a risky undertaking in a critical patient and involves
mobilizing fesources thai may not be avajlable to you. However, if it is a
realistc option ai your instltution, selective embolization of arterial bleeders
deep within the liver can be lfesaving. lf your OR has rntraoperative
angiographic capabilities, the decision is easy, and embotization is
possibie withoui moving the paiient. lt is crucial io make the decision early.
Decide that you are going fof angiography while you ar6 repacking the
liver, noi thfee hourc laler.
Keep in mind that angiographjc emboljzation is an adlunci to effeciive
packing, not a substitute for sloppy hemostasis. lf you didn t pack the ljvef
properly, angiogfaphic embolization will not save your patient.
Decide if you sre dealing with a small problem or BIG TROUBLE
Consider angiographic embolization as an adjunct to packing
6 rhe Injured Live( Ninjo Moster
o c \ ' t t ' /n" ' ' ; c 
' ^ b l " ' t ' t i1
Deep liver sutures L+7 ;'f*J(r. 
'
Deep livel sulures have a bad reputation They 
cause necrosis of tissue
lnclorpJratea in the stitch, predisposing to inlection 
or 'liver {ever'from
;;;;ir*l ntec,iot Do,.t lel rh s bdd 
teoutalior rob vol o{ an
#:# ;;p- " ,",' 
bahre witl^ tnp \rnia Master' espec:ary i{ vou don I
;;".;;;;*";" wlth the injured liver or need 
a rapid bail oui
""ili'"". 
O f,* O"t'*, *ith some hepatic necrosis 
is far betier ihan a dead
Wnen olac nq deep hve- "LLures 
you aust nave a,l i,rlacl caosule to
hol em Wh; ryirg righter ver)/ carelully 
as r vou are tyr'lg a sJrure
ir,-r,*gi oft,go""i [utter' Look for blanching 
of the liver parenchyrna
u."",* ,n. =ut,-r" . w\ ic l 's iqnf:es the sulLrP is t :qhl Cl"oose 
a suru'e
r""a"r"t ' "" Ihat is best lof lhe spec:fc 
anatomiu c 'rcJmstdnces:
il;ffi i;' so,neti,nes uerti"atl mattress' a {isufe of B' 
or a simple-
iffii'""i'tnt""gf', with or wlthoui an omental buttfess 
Regardless or
"o* 
il** configuration, io obtain a good purchase 
of hepatic tissue'
in'" n""J" .""t u,iu"t" tove perpendicular to the surface 
of lhe lrver and
A irap with deep liver sulures is early posioperative 
bleeding As the
rnureo l ,ver swel ls the s ' i lures mdy cJt 
lh 'oLgh the ede'natoJs
pu,"n"t'yt" *'tn 'o"" ot Lne hemoslatic ef{ecl and rebleedilq'
Hepatotomy with selective vascular ligation
This is a useful lechnique to contfol bleeding 
lrom deep in the lrvet'
especiallyif you are an experienced surgeon 
When you s€e anenal
f'"L.rrf'"g" 
".*tn 
ft.. a deep laceraiion' rather than irying to close 
a
;; ; ; ' ; "" ;*" oplen i t w'der ard so 
in l^o nrsLirorrFenddena e"al
iiJo"'" l" 
"""'"o,* 
go to tne heart ot danger lo find sarerv
Deep liver sutures are not a crime
E roa ̂ ",rr rn. on & croft oi Troumo suroerv
With a pringle maneuver in
place, incise ihe hepatic capsute
wfh the cautery io extend the
Iacerat ion, Then, open the
parenchyma In the direction of
the injury using fingerffaciure (or
a blunt metal instrLrment). As you
go deeper into the liver, gentiy
rnsert a pair of narrow Deaver
relractors tnto ihe Jaceration to
facilitate exposure. L,sing this
technique, the liver parcnchyma
orsrntegrates beh,veen your
fingers while ihe ductal
structures remain iniact and carl
be controlled (with ligatufes,
sutures or rnetal hemostatic
clips) and divided, enabJing you
to widen the gap a1o go daeper. We preler to 5uurer.gate all sign:f.cani
orFeders beL€Lse sLtu.er grures do nor shp wher you conr,nue wor^rng
In rne area. t t you use ]relal ne-roslal ,c c, ips. apoty rwo ul ,ps lo each
d uctal 
, 
structu re (double ctipping) to pfevenr stipping. Occasionaly, an
rnlured targe intralobar vein wi l l require laiefal repair using S:Oporypropylene.
Hepaloromy wJr selec-ive vascu'ar ligatiol is a near uoncepr. b i tls
lfelrc.alron 
in the real worid is tess straightforward than the preceding
description leads you to be/jeve. lt invotves significant ongoing btooa toss]
: l l-:::*-nn ,a-,oeenc ,rrLrrro a malo. reparcduct o. h la. vesser. LJce ir onty afler you havF o.ga'rizeo yoLr ailact and
wnen rne pdnent c esLscitated and ca'r io,erate adoilior.t olood loss. lf
you don t have -ucn expef ierce wirh neparic trauma, deep r ivFr sutJres
can Ee a s mpter alternative,
Hepatotomy with selective ligation is easier said than done
6 The Inlured U'er: Ninio Mo'ter 
g
The viable omental Pe'licle
On comple+lon ol ilnger f-acture hePatotomy and seleclve 
vascula'
r;oJln. uo, are tefr w-ith a considerable dead space Fillng 
it wrth
"il""irtti* 
^ o*o idea. The same applies ro a deep 
livet suture where
"'"""ili..""",". 
*" r'relp you achieve hemostasrs ln fact when dealing
*ii 'i" t*,"a ruer, rh" greate- omentum rs one or vour best {riends
lf voJ have time, mobrize rhe greater omentum ofl Ine [ansverse colon
aoniiie tuoauss tine Select a healthy chunk, typically lrom the righi side'
and-separate it by dividing the omentum longitudinally toward the 
greater
curve of the stomach.
Swing the mobilized
tongue of omenlum uP
into ihe iniured livet
and fix ii to ihe Lrver
capsule with sevefal
loose stitches. Another
option is slufling the
omental tongue iightly
lnto the laceration,
{illing lhe space, and
then approximaiing the
laceration loosely wlth
several liver stiiches
over the omental Pack
Some surgeons use
omentum {or Packing
{rom within insiead of
laparoiomy Pads or
gauze rolls.
Fill large parenchymal defecb with omentum
IOP KNIFE The Ad & Croft of Troumo Surgery
Balloon tamponade
When dealing with a
t h r o u g h - a n d . i h r o u g h
(transfixing) lver injury,
whrch rnay occasionally
Invoive both lobes,
renrember the option of
bailoon tamponade - an
Ingenrous and easy
solution to a very bad
problem. The alternairve
is erlensjve iractotomy
to achieve direct
hemostasis.
lf the tract is wide (2cm in diameter or more), we use a Blakemore tube.
Insed the iube into the tract so that the gastric balloon, inflated outside the
exit wound from the liver, will serve as an anchor to prevent drslodoement
of l le ruoe. Then genry i r , latF rhe esool^ageal oaloo,r r . the tai t u-r i l
bleeding stops.
lf the tract is ioo narrow or ioo short for a Blakemore tube, we improvise
a balloon lrom a .ed .Lbber carheter and a pe'rrose drain. T,e ofl onpend of
the drain with two heavy sitk ties. Tie the other end afound ihe catheter.
creaiing a sausage-shaped bal/oon. Check the balloon for leaks bv iniectino
cal ine r l rough the reo .Lbber calherer ard La-pirg f . ne'aevce, i
working, insert the balloon into the lract and brjng the oiher end of the
catheter out through a stab rncision in the abdominal wall, as if it were a
drain. Inflate the balloon and watch bleeding stop as if by magic. Secure the
red rubbef catheier io the skin and make sure the end is ciamped.
You can safely begin removing the balloon at ihe bedside after 24-4g
hours. Firsi deflate the device, but keep ii jn place for 6-8 hours. lf ihere
is no cl in icalevidence of bleeding, pul l the bal loon oui l ike you would afv
olher drai f .
Balloon tamponade is a cool solution for a bad problem
6 The Lniured Liver: Ninjo Mosler
Resectional debridement
When a subslaniial part of the hepatic lobe is desiroyed and bleeding
orofusely, ihe most expedient opiion is reseclional debridemeni Have 
your
^"ai"t"ni n 
"nuully "otpress 
lhe non'injured liver parenchyma around the
area you wish to resect lf the lobe ls properly mobilized' o{ien 
your
assiint wiLl be able to completely encircle ihe injured part' minimizing
blood loss whlLe you do the reseclon
Turn the cautery lo maximum and use it to de{ine a line of resectlon thai
is immediately outside the injured area in healthy hepatic tissue Always
resect imrneiiately outside the injured area where the vessels ate iniaci
and have 1or rer;credi "_j.=-jj!I:El_!jg] 
rh,s is ,he \ev
maneuver of resect onal debndemenl
Perform finger fracture (ihe 
'pinched corn bread' maneuver) and
selective ligati;n along your chosen !ine of resection The slmplest
example foiuse of this technique is resection o{ the left lateraL lobe along
a llne imnrediately to the left of the lalciform ligament Some surgeons Llse
a linear cuiting stapler wiih a vascular staple load io faciliiate ih s non_
anatomic hePatic resection
Much like hepatotomy and seleclive vascular ligatlon' reseciional
debridement takes iime and involves conslderable blood loss Don'l
aitempi it in a Patient rapidly dving on the operatlng table Organ 
ze youf
aliack and resuscitaie ihe patient before you begrn
Othel techniques
The traLrma literatrrre is repleie with many techniques that resourcelul
suroeons have developed ior dealing wilh bad liver injuries One example
is tie absorbable mesh wrap. By snugly Jitting a 
'pita of absorbable mesh
around a shattered obe, ihe advocaies of this technique achieve elfectlve
iamponade, avoid ng lhe need for packing We find this technrque
c!mbersorae and do noi use it,
Perform resectional debridement in healthy liver tissue
TOP KNIFE The Ad & Croft of Troumo Surgery
Hepaiic artery ligation is siill meniioned in trauma texts as an effective
hemostatic_ techn iq ue. Some surgeons use ji for ongoing arterial bleeding
noi controlled by oiher means. We have not used this iechnique in years.
How about drainirg the inlured ljver? This is a somewhat controversjal
iopic. One of us routinely drains all high-grade liver ifjuries using a closed
suctiof drain, while the other almosi never does.
Rehohepatic venous iniury
Gushing dark blood from a deep hote in the tiver or from behrnd afd
around t usually means an njury to either the retrohepatic IVC or hepatic
veins. These encounters are rare, brief, and brutal. [4or€ often ihan fot,
the result rs of-table exsanguination and a very frustrated surgeon.
The retrohepatic veins are ihe east accessible vascular siructures in
the abdomen. You cannoi get to them and define the injury unless you
somehow control the hemorhage. The classic technique to accomplish
this rs the atriocaval (Schrock) shunt, one o{ ihe ,,great technical feats,,of
trauma surgery. You willfind elegant lll!stralions deprcting ihe technique n
every malor trauma book, bui not rn ihis one. Why? Because if real life il
very rarely works. In fact, even rn the most expeienced hands, the
atriocaval shunt has drsmal results.
l rstead of engag ng in Jut le heroics, use common sense. The
retrohepalic vetns are a lowpressure sysiemamenable to containment
and tamponade. Your best move, therefore, is to contain the injlry, not try
and fix it. A retrohepatic venous injury bleeds freely only if one or more of
i ts containmert structures is disr!pted. These structures are ihe
suspensory ltgamefts of ihe liver (markirg ihe borders of the bare area),
ihe right diaphragm, and the liv6r itsetf.
Your realistic opliofs for dealing with a retrohepatic venous injury are:
a Leave a contained retrohepatic hematoma alone. Don t mobiljze the
liver and don I try to explore the hematoma. Just move on io other
injur ies {and count your btessings).
a
a
6 The lnjured Liver: N njo Moner
l{ dark blood is gushing out from a deep hole in the liver parenchyma'
pLug the hole. Pack ii with a laparotomy pad, viable omentum' or
balloon iamponade. Whatever ii takes - iusi plug the hole'
Don't open 'Pandora's Box (Chapter 10) A hole in the r ight
diaphfagm bleeding inlo the chest in a patieni wlth penetratrng
thoracoabdominal trauma can hide a retrohepatlc venous rnlury
Simply close the hole and don t mobilize the hver'
When bleeding emanates ffom behind the liver, iry to determine if the
source is below or behind the liver. Injuries to ihe IVC below the liver
(ihe pararenal and suprarenal segments) afe accessible to direct
repair. lt's difficult, but can be done.
lf the suspensory ligamenis of the liver are distupied, your best
chance to control the bleeding is packing ihe area quickly and tightly'
Wiih limted disrupiion of the ligamenis, you may be able io re_
esiablish conlainment with packing. Wiih massive disruplion, often
associated with a high-grade liver injury the battle is usually losl even
before you siad Packrng.
Should you even consider an atriocaval shunt? lt may be a realistic
option, but only under very speclflc circumstances' You need two teams
of experienced surgeons who can work simullaneously in the abdomen
and chest, the necessary equipmeni must be available, and bleeding must
be temporarlly conirolled while ihe effod is organized
The techn que entails a med an sternotomy, a purse_siring suture In lhe
right atrial appendage using 3:O poLypropylene and a Rummel tournlquet'
and encircling the supradiaphragmaiic IVC inside the pericafdium wiih an
umbilcal iape on anoiher Rummel iournlquel We use a size 
g
endotracheal iube, clamped proximally, with a side_ho e cui 17cm Jrom the
tio. We insert the shunt wiih the curue of the lube facing anterlorly so that
the lip does not end up in lhe hepaiic veins The surgeon operating in the
abdomen directs placemeni to prevent shunt efrusion through the injury
The baloon or lhe IuoP oovia-es lhe need 
ror encrc ng t1e s ' lora-erel
IVC in the abdomen. The shunt does not provide a completely dry field bui
ooes arlow yoJ to see .he inlLry and gel Io t
a
a
ln retrohepatic venous iniury, restore containment - don't be a hero
IOP KNIFE The Art & Croft of lroumo Surgery
The "evil green eye"
For obvjous reasons, injuries to the bjliary traci are often assocjaled
with hepatic trauma, and leaking bile is a jower priorityihan spurting blood.
What are your damage control and definitive repair options for the injured
biliary tract?
A perforated gallbladder can be repared, drained, or femoved. The
def ini t ive solut ion is that rare, almost ext inct operat ion , open
cholecystectomy. ln a crashing coagulopaihjc patient, taking the
gallbladder off the liver is not the smartesi move in the book. tnstead,
either repairthe laceration wjth a single layer ofabsorbable suture or drain
the gallbladder with a cholecystostomy tube inseded through the injured
fundus and secured with a purse-string suture.
The damage control soluiion for cor.mon bile duci injuries is exiernal
drainage. lfyou need to bailout in a hurry, cannulate ihe proximal duct and
bring the drain out through the abdominal wall. Ligaiing or clipping the
common duct ofa patient in dire siraighis is an acceptable darnage control
opiion, but will require a complex reconstrucilve solution at reoperation, lf
you can' l see ihe leaking hole, a drain in Morr ison's pouch is good
enough. The leak can be managed later by ERCP and endoscopic
stenling.
lf you can clearly see ihe injury and the com.non bile duct is wide
enough to accommodate a T-tube, this is a good bail out option. However,
the common bile duci of most young irauma patients is narrow and
delicate, and inserting a T.tlbe into it may well buy youf patieni a
posloperatve stncture,
The definitive repair of extrahepaiic biliary injuries depends on the
magnitude of damage. Repair a simple laceration (partial iransection) with
an absorbable sut!re and an external drain. Allhough it is not mandatory
we lnsert a T-tube in the common bile duct if it is of sufficient caliber to
accommodaie at /east an I French tube. If you decide io use a Ttube,
always insed it ihrough a separaie choledochotomy rather than ihrough
the Inlury sile to preveni a stricture.
6 The Iniured Llven Ninio Moner
Deflnive repar of complete or near_compleie transeciion of the 
bie
duct is with a Roux_en Y hepaiicojeiunoslomy Before you begrn' a
cholecysieciomy willfaciliiate access and exposure of the injured duct
Drainage is the bail out solution for biliary trauma
T H E K E Y P O I N T S
) Control the l ivef tempofar i ly using hand, pack, or c lamp
) lvlobilize ihe iniured lobe to deal with it face{ojace
> Decide if you are dealing with a small problem or BIG TROUBLE'
) Consider angiographic embolizaiion as an adjunci io 
packrng
) Deep liver sutLrres are noi a crime
) Hepatotomy wiih selective llgation is easier said than done
) FiLl large parenchymal defects with omentum
) Balloon tamponade is a cool soluiion for a bad 
problem'
) Perfom reseciional debridement in healthy liver iissue
> In fetrohePatic venous lniury' festore containment'don't be a 
hero
) Drainage is ihe bail out solution for blliary irauma
TOP KNIfE The Ari & Croft of Trqumo SLJrgery
Chapter 7
The 'Take-outable" Solid Organs
Fot eztery complex ptoblem, thete is a
solution that is simple, neat, dnil Tototrg'
- H.L. Mencken
Although they belong to different organ systems, the spleen, kidney,
and dlstal pancfeas have a lot in common From the trauma surgeon's
perspective, they af€ close relatives because they are 
'iake_outable '
Consider the fundamenia dlffetence between an injured spleen and a
bleeding liver. The spleen has a single accessible vascular pedicle thatyou
can rapidly gel io and control The liver has two vascular pedicles (one in
lhe hepatoduodenal ligament and ihe othor behind the liver where the
hepatic veins drain into the IVC), only one of which ls easlly accessible'
Toial vascular control of lhe liver is, therefore, iricky businsss lt is noi a
take-outable organ in the bleeding irauma patient.
It n6ver mad€ sense io us to consider both head and disial pancreas
(body and tail) in ihe same chapter' From lhe irauma surgeon s poLnt ol
view they are differenl organs The distal pancteas can be easily resected'
while the panctealic head requLfes a very brg whacK
The spleen, kidney, and distaL pancreas are take_oulable abdomlnal solid
organs. They can bleed a lot b€fore you get to them, bui once you have
gained control of the vascular pedicle, bleeding stops immediately The key
to vascular control is mobilizing each organ and fting it toward the midline
In stark contrast, resection of a 
'non'take_outab e ' so d ofgan such as lhe
liver or ihe head of the pancreas is a prohibiiive technical undertaklng in the
lrauma patient unless the injury has done most of the resection tor you'
At firct glance, bringing together three solid organs from three different
organ systems under the same foof may seem strange to you Bear with
IOP KNIfE The Ari & Croft oJ Troumo Surgery
Lis, and your undersianding and comfort jevelin dealing with these injuries
will grow
The spleen
Mobilization
. If 
you see or suspect a spienic injury your first move must be mobilizingthe spleen to ihe midline. You can nejiher adequatety assess nof repairthe
spleen wiihout having ii tn your hand. Mobilizing the spleen is the key
maneuver that unlocks the left upper quadrani. lt brings the sp/een and
drstal pancfeas oui of the dark recesses of the abdomen jnto your incision
and exposes the left kidney. White mobitizing the spteen is a basic
maneuver rn surg€ry, pedormjng it quickty, btindty, and tn a poot of blood
is not as it appears in the illushaiions.
Mobilize the epleen to unlock the left upper quadrant
You may not have heard this before,
but in reality (as opposed to the virtual
world of the surgical atlas), ihere are
two kinds ofspleens: mobile and siuck.
The mobile spleen has lax spleno,
renal and splenophrenic ligaments
and no adhesions to the abdominal
wall. By putting your non-dominant
hand over the splenic convexity and
pul l ing medial ly, you can brng the
rnobile spleen toward you, almost io
the rnidline. You still have 10 cut the
splenorenal l igament behind ihe
spleen, but this is easy because you
do it a/mosi in the midline raiher than
high up in the left upper abdornen.
The spleen, kidney, and tailof the pancreas are take-outable
7 The Toke-oLrtoble So icl Orgons
The siuck spleen is, you guessed ii' siuck To gel it to the midline' 
you
have to deal with two obstacles. The firct are adhesions beiween the
splenic capsule and lhe abdominal wall ihat will not let you pass your nano
over the splenic convexity- lfihere is little or no bLeeding, you can take 
your
iime and ;harply divide ihe adhesions with scissors or cautery But if 
you
are working in a poolof blood, just do whalever ittakesto quickly gel them
oui of ihe way with your fingers, scissors, or boih Damage to ihe splenlc
capsule doesn t matier since ihe sPleen is coming out anyway
The second obsiacle wiih ihe stuck
spleen ls a short and unyielding
splenorenal ligament. Put your non-
dominanl hand over the spleen so the
tips of your fingers resi on the
menrbrane behlnd and lateralto it This
is the splenotenal ligamenl Gently pull
the spleen toward you io stretch ihe
ligament. Working in a pool of blood,
you often cannot see [, bul you can
easily leel it. lmmediately beyond the
tips o{ your fingers, make a nick in lhe
streiched ligament wiih your scissors
Enlarge the-nick sharply (with scissors) or bluntly (with your {ingers) up
and a;ound ihe spleen Both the splenorenaland splenophrenic Ligaments
are avascular' and dividing ihem
allows you to bring ihe spleen to ihe
midl ine.
Palpate the left kidney and bluntly
develop the plane behind lhe spleen
and in iront oi the kidney, bringing the
spleen and tailof the pancreas up into
the wound. The piifalL here, especLally
in the prcsence of masslve bleeding'
is going behind the left kidney and
discovering thatyo! have brought lt t0
the midline wiih You.
TOP l(NtFE The art & Crofl of Troumo Surgery
Once the spleen is mobilized and
in your hand, bleeding control is not
a problem. Pinch the splenic
vascular pedicle, which includes
boih the gastrosplenic l igament
(carrylng the shod gasiric vessels)
in front and the splentc hi tum
behind. Alternatjvely, place a soft
bowel clamp or a large vascular
ciamp globally across the entire
pedicle if you have other urgeni
business to aitend io first. Think of
t as the "Pringle maneuvef of ihe
spleen."
Remooe ot rcpab?
You are now facing the key slrategic decision ln sp/enic trauma: romove
of repair? Splenectonry or splenorrhaphy?
Rarely, on a particutarty bad night, you may find yoursetf gazing in
disbelief ai the ruptured spleen from hell, a diseased organ so enlarged
and stuck to the abdominal wal/ and diaphragm ihai rapidly developing a
plane behind ii is slmpy oul of the question. ln this case, your only option
rs 10 altack the spleen from the front. One qulck way to conirol the splenrc
arleryis to enre. rhe lesser sac lhrougn the gastroco ic omentum a,to
isolate ihe artery along the upper border of ihe pancreas. Another oDtron
is io go srrarght al lhe hilLm. Gentry pull tne stomach towaro you Lo put tlF
gastrosplenic ligament on tension and divide it between clarnps.
lmmedialely behind rt you will find the splenic hilar vesse s. Clamp them
and only then start yo!r dissection io fiee and mobllize the devasculafized
Do what it takes to bring the spleen to the midline
7 The Toke ouiobe solld orgons
Your answers 10 the iollowing fout quesiions guide your decLsron
1. What is the patienl s traun''a burden? Ongoing sl^ock s"vere
associated iniuries in or outslde the abdomen _ all are indications to
rapidly Put th€ soleen In a bJclet.
2. Whai is the patieni's age? Spenjc pr€seruaiion is much more
important in kids. Splenonhaphy also works betier ln the pediatrlc
spleen because it has a lhick capsule ihai holds suiutes welL'
3. iow bad is the iniury? ls a repair llkely to work? ls there a hilar iniury
that makes repair much more dif{icuh? Will a r€pair entail additional
bLood loss? Never make this decision wilh ihe spLeen in siiu Always
bring itto ihe midline and assess the lnjurywrth the spleen in your hand'
4. Wh;t is your experience wilh splenic tepalr? Have you done it before
or is i t a ' read ons, do one'si luat ion? ls the injury amenabLe to a
reparr iechnique ihat you are comfortable wiih?
t ,l compteung the s1lenecto,nq
."t /' CJi""'y Lo the imor€sson you may havo fro.r reading 
the rauma
7 t I literalure ol the pasl decade, splenectomy is not a crime lt is otten ihe
safest and mosi expedient solution One very effectlve technique of
splenic preseruation is the {omalin jar
Once you have the mobilized
spleen in your hand, comPlel ing
the splenectomy is easy Clamp
and divide the vessels of the
splenic hilum from the back or
side, whichever Ls mosl
convenieni. The key technical
prlnciple here Ls to stay very cbse
to the spleen so you wi l lnoi in jure
the tail of the pancreas or lhe
siomach. Fot the sake of sPeed,
For splenic repair, considertEuma burden, age, injury, and experience
TOP KNIfE The Art & Croft of Trouma Surgery
camp oniy ihe proximal side of the line of resection. Clarnping the spleen
srde wastes time since it comes out in a moment anyway, Serially clamp
and divide the gasirospJenic ligament, taking care to stay away frorn the
gfeater curve of the siomach. The splenocolic ligament is ihe only
remarning attachment. Clamp and divide ii, and the spleen is out.
Now pick up the ciamps one-by-one, and ligate the vessels ihey are
controlling. You may declde to doubly ligate or sutureligate the hilar
vessels. Re-examine the greater curue of the stomach to ensure you did
not accidentally pinch the gastric wall. Much has been written about
ratrogenic jnjury to the tail of the pancreas during sptenectomy. Thjs
concern rs much overraied. lf you think that you may have iniured the
pancreas whie removing the spleen, leave a closed suction drain in the
splenic bed.
Lasty, check for hemostasis_
Suck oui al l the b ood and clots in
the splenic fossa. Take a tighty
rolled laparotomy pad, go io the
deepest part of the splenic fossa,
and slowly ro/l the pack ioward
you medially, over the area of ihe
pancreatic tail and the greater
curve. ll you identify a bleeder,
stop rolling and deal with it.
,..\
ij
Stay close to the spleen
\ ^ Y r {
Fixing the injurcd spleen
lf you decided to repair ihe spleen, use ihe simplest technical solutron
thai will work. Choose fronr a limiied menu of repair rechniques that have
worked fof you in ihe past. Few surgeons have experie|ce wjth a vasi
array of spjenjc repair methods. What are your realistic opiions?
7 The Toke oulobe SoLid O'ncl"t E
Local pressJ'e lwrlh yor- hand-or a 
pachl wor\s in super{ 'c ia
laceratro']s and capsLlar avu's;or- Your lavorfte 
rocdl hemostairc agert
""" 
.f". n"fp fn" ,q,g"n beam coaguiator' if 
availab/e' does wonders for
a larger raw surface or a deeper laceration-
Because the caPsule of lhe
ad!lt spleen does not hold sunrres
w€ll, use a rnonofilarnent suiure
ihatslides through the tBsue,
along with some klnd of bolster or
support. Our PreJerfed technque
is running a mono{ilament suture
on a straight needle between two
stdps of Teflon on both sides ol
ihe laceration Sorne surgeons
use omentum as a boLsler.
A severery rlu'ed or o^vitalireo soleniu pole ray 
r"qu're a "mired
;;;". #"" ;"", """istant 
manuallv compress the spleen lusi bevond
;; , ; ;""" l i . " ; ' ' """" Ion .o conrol b 'eedirg lntermit .nt lv 
reeasi 'g ihe
0."J",'" .**. t", **'e the olPeders are -o vo"r::: 
':lH 
T,i.il
Argon beam You can then
oversew the op6n splen|c
's iump' with matt fess
sutures between two sirips
of Teflon. lf the sPleen Ls
flai rather than bu kY,
another oPtion is using a
linear staplef wiih 4 8mm
staples. Bring the stapLer
io the line o{ transection
and slowly close I so as
noi to break the caPsule.
Fire ihe staPler and
amputaie the sPlenic tissue
disial to the staPled line.
E ,o, ^",r, rn" o,, & cfofl of Tfoumo sureery
-, 
Don't persist ifyour repair doesn,t work, and don.i reiy on the patient,sCott'ngmechanism to sioo orgoing oozirg. ,lf i air,, ary. ,t s noi wor"r,.g."In ar adL[ patient. we proceed wttn splenectomy i, rhe fts, aftemp;drepairJaits. tf you sirongty betieve thai repair is stifitf.," Uu.t option tofifrJpalient, you may try a second time_ A tnira atrempt rs ptaying wirh fjre.
_ 
We have.g:ven you ihF hmied.ienu of sptenrc rsoair ,ech n iq uFs we Lse
:,:1:li::i"", 
sorry if you are disapporn,ed. We have ,itr,e experielcewllr Tormat tem,splenectomy or tre absorbabte mesh wrap. We consioe.rnem unlecessaflly risky acrobaics. lr siuatons where these tech'rrqueswould be requhed, we prefer io en on the srde ot caution and do asprenectomy.
Don't persist if splenorrhaphy doesn,t work
The distal pancreas
ENplolation
You can have a quick'rule
oui' look at the body and tail
of the pancreas thfough the
lesser sac by poking a hole
In the gastrocoiic omentum
on the tef t (Chapier 4).
However, i f you see or
suspect an injury, you need a
wrde exposure. Have your
asststani pull ihe stomach
upward and ihe transverse
coron downwardr and detach
the greater omgnium from
the transverse coJon a/ong
the bloodless line io open
the ful/ width of the tesser
sac. Wjih any sign of Injury,
open the posterior peritoneum overlying the 
injured area What.you
;;"";; i" be an innoLenr-looking minor hernatoma 
or superrical
i"""*." *,, .f,"^ oro"e a s€t;ous Injury wh"n you un'oo{ 
it and look il in
fie lace.
7 The rake-oirioble soio orgons I
For signi{icanl injury, and
especially if You are going lo
resect the dislal Pancreas, the
quickest way io bring ihe body
and tail into {ull view (including
the posterior asPeci of the
gland) is to mobilize it out of ils
bod. Mobilize ihe sPleen and
continue to develoP ihe Plane
behind the Pancreatic iail and
body until it can be lifted
medialLy lnto the operative
incision. Distal Pancreateclomy
without splenectomy rs an
€laborate exercise suitable
mosily to an elective situatron.
We do not recommend nor use
it in trauma panents.
Decision
ls thete a ductal injury? This is the key quesuon whan assessrng 
Ine
iniured pancreas someiimes you immediately see that ihe 
pancreas ls
;;;;iJ 
", 
vou can rdenlily lheinruted duct 
in a deep wound ['4ore
ot 
"n, 
you 
""n;ot 
tu," out a duclal 'niury based on Inspeclioi and palpanon
alone. What then?
Iook 
"t 
the pan"reat from the front - but mobilize it from the left
E ,o, *",rr rn" orr & cfqfj of Troumo surgery
ln a stable patrent wiih no othef maiof inire,ercise ca red,nraopar,, 
"; r";;.;;;:;#;:;jJ:i;T,:lj"'j;::ilI:II.e ga,'bladder rrrough a reedle and 
-catn.rer 
aro pray rhar rt n,ts trepancreatic duct in a retfograde fashron ihrougt th" urputu. eropon";iiof this technrque cJaim ji works about half the time. In 
"rl. ",,p";i;n";;;ra,'ely does. B.euaLsp lhey a,e toratty Lnnece,sary, we don | -euommero
olTer opfons I ke ampurat ng tne ta,r or t re panc.ea5lo n^o the dJc- or Ineabsurd notion of making a duodenotomy io cannuJate the papilla.
-^Y" ! ' :* 
r : : c:Tmon sense. . \pedien- aop,oacr. f Fypto.aion
revears a oeep InJUry l iJ<ely to. .vorus,1.," 6u" ' , Oo 1ol hesi tate ro pertor_a orslat pafcreaiectomy, even wiihout definitive proof of ductat injury. lf we
P:^r, ] : l 
* ' : ""1 
" ."eed-o 
bait oL, oLiLkty. w" , ,""" 
" 
o." ,n 
" ; ; ; ; ; ; ,'o lhe InJLry dnd perform ar ERCp as \oor as oossib,e afte. ihe operairor,
fealizrng thai we may occasionally have ro go tJack for a disial
Hemostasis alriL ahg Mge
The damage control soluiion for injuries to the pancreailc body and tailrs hemostasis and drainage. pack *e lesser sac for hemosiasis. A drain
converls ihe injury from a potential uncontrolied pancreatic leak into acontrolled fisiula ihat has a befign course afd can be addressed laier
, .Def.ni :vF 
mdnagFmenr oi mosr drslar panc-eaic injLr ies is no_ -uch
i i l ' " : ' "* 
1l^e damage co' lnot ooiro' l . Slop b,eFdrrg from supFtiL a,
raceratons and conlusions using localhemostat ic means. Don,t sulure ihecapsule of ihe pancreas because this js asking for trouble. Leave a Jarge
suctrojl drain,(or two) adjacentlo the injury, feed the patient as early;s
possrbre, and renrove the drain when it stops working. For pancreatic
injuries that do/r't involve the duci, ihis is a yo! need to do.
^ ^ryTl 
*" ,s oovious ouda :njury or when you have d srrong
suspruror about the d rct bur ua-no- prove i l . do a drsta,panc.eatecromyi
You don't need photographs to deal with a pancreatic injury
7 The Toke-ouioble Solid Orgons
lf you happen to come across the
pancreata duci, ligate it Otherwise,
don'i spend time looking {or it. Liit
the spleen and the Pancreas to the
midline, lake a linear stapler, place it
across ihe body ol the Pancreas
including ihe splenic vessels, and
shoot. Amputaie the disial pancreas
and spleen and give the Pancrcatic
stump a close look Control any
bleeding from the splenic vessels
with a hemosiatic atiich. One ol us
usually undeffuns the siapled line
with a 3:O monofilament non-
absorbable suture; the other nevet
does. Don't forget to leave a closed
suction drain in ihe pancreatic bed
Damage control lor the distal pancreas is hemostasis and drainage
-''N5t(^\D\-- 
'+ @ *"*tH
The kidneys a s!,rl,r" + c.^l,alt r'.-{,&}.-&
Access &nd otlscttltu contxol
At laparotomy, the iniufed
kidney iypically presents as
a lateral feiroPentoneal
(perinephric) hematoma
(Chapier 9). Deal wth a
massively bleeding kidneY
in an unstable Patient b),
rapid mobi l izai ion and
contfol of the vasc! lar
pedicle, just l ike You deal
with the iniured spleen A
E ,o, *"'rr rn. o,r & crofi or TroLJrno sursery
mediai visceral rolation (Chapter 4) on the left or on the right gives you
ftpld access to the injured kidney. Incise Gerota's fascta taieratty anj iift
the kidney out of its bed. Now you can pinch the hitum with your fingers
and carefully place a vascular clamp across tt to control the bleodino. The
obvious sjmilariiy to th6 spleen is stfrking.
Bring a massively bleeding kidney to the midtjne
l f you must explore a
pennephflc hematoma In a
Egllq) patjent, you can gain
vascular conirol of the renal
vesseJs at their origin by
using a maneuver cal led
nidline looping. Wilh this
maneuver, you obtain proximal
control prior to entering the
hematoma, but ai the price
of tedious dlssection. The
lrrst moves are essentially
those of infrarenal aodic
erposure, Eviscerate the
small bowel and pull it up
and to the right. Take down
the ligamont of Treitz and
open the poaterior periioneum
overlying lhe aorta. First, identify the LRV crossing in front of ihe ao a
beneath the infefior border of ihe pancreas and encirc e t with a vessel
loop. This is the first of four toopings. Very gently reiraci the LRV
downward (withoui avulsing the adfenal, left gonadal or lumbar veins
that branch of{ jt), and you will gain access to the left renal artery taking
off irom ihe ao a behind andabove the LRV pass vour second vessel
loop around i t .
Midline looping is trickier on the right_ you must first identify and looD
ihe srorl right'enal ve:n: then. dissect n tne wrndow betwee; t and tne
IVC to oop the right renal ariery as it emerges from behind the IVC. AJI
7 The Toke ouloble Solid orgons
this is iime_consuming and opens the door io potential 
pitfalls We
consider it a long run {or a short slide and rarely use it You can easlly 
get
tv without it if vo-u rememberto rapidly liftthe injured kidney io the midline'
iusi as you do wiih the sPleen
What af€ the damage
control opi ions for renal
trauma? One obvious
option ls nol to explore the
kldney. lf the PennePhnc
hematoma is slabl6 and
non-expanding, leavo i t
alone. lf you see oozing but
no massive hemorfhage
through a hol6 ln Gerota's
{ascia, pack the krdney
Remember thai ur ine
exiravasalion |s much less
ominous than leaking
intestinal conteni (Chaptet
4).
lf the kidney is bleeding massively and is obviously not amenable lo
reconslruction; ot has a hilar vascular lnjury in conjuncrion with oiher life_
lhreatening iniuries, a rapid nephrectomy is lifesaving Lift lhe mobilized
kidney up, id;ntify the artery and vein, sutureligate the artery and tie off
ihe v;in. Then, divide th€ ureter between ligatures and pui the kidney in
When considering your oPtions, always think about the contralateral
kidney. You will go the extfa mile and invest addltlonal effod in renal
preservation ifyou know thatthe paiient does not have another functioning
iidnev. lf vou do not have preoperative imaging to prove afunctloning renal
mass on the other side, what should you do? An on_table intravenous
oveloo.ar to prove ihe presence ol a lLnciion ng confalatera renal 
mass
is ore'option. Tl^is takes t -e and otler yields an rrialing lLzzogram ralher
than a satisfactory image A better option is to palpate lhe othet kidney lf
it feels normal in size and consistency and the patient is making urine
TOP KNIFEThe A.t & Crof l of ]rounro Surgery
despiie a. hilar clamp across the injured kidney, the risk of postoperative
renal dysfunction is very small.
Palpate the contralateral kidney
. 
Repaif.oplions Jor the injured kidney cover a wroe epectrumj ranging
lrom application of top ical hem ostatic agenl to extracorporeal bench repair
wrth auiotransplantation. The best advice we can give you is don,t use
them. CaJl a urologist in to repair the kidney. An experienced urologist is
more likely io achieve a good result, will foliow the patieni, and m;nage
any cornpllcanons.
/ . 1 - J V , r 
^ 1
Repair of renal vascular injuries (both blunt or peneirating) is much iess
coramon and rnore challenging than the trauma iterature leads you to
believe. On the right srde, penetfaiing hilar injuries are iypically part of
wounds to ihe surglcal soul one of the most devastating combinaiions of
injuries in tfauma surgery (Chapter O). The proximity of the renal hjtum to
ihe IVC means that a penetrating injury will involve boih ihe renal artery
and lhe IVC or other adtacent siructlres like the pancreaticoduodena
complex. Inj!ry to the short fight renal vein is essentially a side-hole in ihe
IVC, for whlch the pime concern is control of liJe-threaiening hemorrhage,
not renal salvage. On the left, don'i hesitate to ligate the renalvein if it ts
Inured proximal to its gonadal and adrenal branches. The N4attox
rianeuver (Chapter 4) gives you excellent access to ihe left renalartery.
When dealing wrth an ischemic kidney after bJunt iralma in a stable
patieft, your decision to revascularize ihe kidney hinges on ihe Ume
elapsed since injury, presence o{ functionjng contralateral kidfey, the
patieni s overall trauma burden, and availabie expertise. l\,,lany of these
Inlunes are amenable to endovascular stenting, Never jeopardize the
patient's lile to save a kidney.
ll you are fixing an inj!red renat ariery, perfuse ihe kidney intermlttently
with iced heparinized satine and choose the sjmplest repair optiof. Jf the
artery can be repaired end-to-efd, go for it. More often, you have io
interpose a graft. The graft of choice is probably a reversed saphenous
vein, bul ihe most expeditious option js a 6mm epTFE condujt. Hook it up
7 The Take-outoble Solid O,S.", 
g
io ihe renaladery (distal anastomosis) first because this allows 
you better
".|e"" 
," tr't" posterlor *atl of the anastomosis Choose a convenient
L"ation on tne lat"rat u"pect of the inftarenal aoria' convol ii wiih 
a side-
Uiti"g autp, and do a small aoriolomy Trim the graft and comPlete 
the
pror-mal anastomosis lo the aortotomy in an endio side confiquration
T H E K E Y P O I N T S
) The spleen, kidney, and tail of the pancreas are take_ouiable
) Mobilize the spleen io unlock the left upper 
quadrant'
) Do what il lakes to bring the spleen io ihe 
midline
) For splenic repair, consider trauma burden ' age' 
injury' and experience
) Stay close to ihe spleen
) Don t persist if splenorrhaphy doesn t work
) Look at ihe pancreas frorn ihe tront-but mobilize 
it fior' the leJi
' You don't need photographs to dealwith a 
pancreatlc rnlury'
) Damage control for the distal pancreas is hemostasis 
and dfaLnage
) Bring a massively bleeding kidney to the midline
> Palpaie the contralateral kidney
) Don t killthe patieni while irying io save a kidney
Don't killthe patient while kying to save a kidney
E ,o. *",rr rn" o,r & crofi of Troumo su,sery
ChaPter 8
The Wounded Surgical Soul
t!a-,.'a^* e 
(vQ i^ "/''r+vu'! t ')u7
Medical ill strators arc optifiists.
It's dilficult io imag ne
a more unwelcome sight
during laparoiomy ror
penelraiing trauma ihan
a arge hematoma or
vigorous bleeding kom
the dght upper quadrant
beneath the Liver. l{ ihis is
what you see, you have
just been dealt one oi ihe
worst possible hands in
the l rauma game. We
cal l ihese injur ies the
wounded surgical saul
- Matthew J. Wall, Jr., MD
l.
According to iraditior in
our hospital, ihe seat of the soul of lhe injured patient is a sphencal area'
not much larger than a silver dollar, centered on the head ol the pancreas
They afe called soul wounds because they are mofe lethalthan any other
type of abdominal trauma
A glnshot to ihe surgical soul commands ihe greatest respect from
trarmi surgeons because i t f requent ly eads to intraoperat iv€
exsanguinat ion. You may ini t la l ly encounter a contained or slowly
expan;ing hemaloma lhat doesn'i look particularly ominous But once 
you
open it and unroo{ the underlying major vascular injuries, the demons are
unleashed and the pat ient exsanguinates in your hands Another
unwelcome s!rpdse is when a novice pokes an exploring Iinger into a soul
wound, onLy io face torreniia hemofrhage when the ptobing finger is
withdrawn. Why are these nluries so Problemaiic?
E ro, *"'rrTn. o,r & CroJi oJ Tfoumo su,oerv
First, consider the vascuJar anatomy of the area. The portal vein, the
s!penor mesentefic vessels, the pancreaticoduodenal arcade, the IVC
and the righi renal pedicle all converge ai the surgical soul. Since some of
ihese vessels directly oveflay each other, a penetrating injury iypically
in/olves more than one major vessel. Now consrder accesstbtlty, The neck
or tlre pancreas overies the podal vein conJluence and the proximal
superior. mesenieric vessels. The pancreatic head and duodenal loop
(reJerred to in ihis chapter as the pancreaticod!odenal complex) cover ihe
IVC and right renal pedic/e. So, none of ihe vessels is easily accessible.
The situatron has worst-case scenaio wrjnen al/ over it. A discipllned and
priorrty,oriented approach is your only hope.
Immediate concetns
Yolr first priorty wlih soul wounds is to contro her.orrhage. Always
assr.rme lhal bleeding is from more than one major vascular injury unti
proven otherwise. The major bleedlng sources afound the surgical soul
are arranged in ihree layers: deep, middle, and superfrciai.
2.
L fhe deep layer includes
ihe IVC and the righi renal
pedicle. You wil l see a
raprdly expanding r ighr-
srded retroperrioneal hem-
atoma or active bleeding
from the area of the righr
renal h Ium- Pack or
manuarry compress i t .
Don't unroof it.
fhe niddle layer irc)udes
tfie retropancreatic vessels:
the superior mesenter ic
artery (SIMA) and vein
(SMV), and the portal vein.
The secret of tempofary
b eeding control ts rapid
mobilization with a Kocher
-\ j i . ' . - ----- ' - ' - .
\:1,- -:1.)
sThe wounded sursrco sou 
g
maneuver (Cl'dple'4). lf bleeding is {ron the 
rool ot lhe mesentery
iJ"t i."rJ., ,"f *" o"ncreas' control it by insinuating your 
lelt hand
s.i-i"a'iil ."t or tr',..eseniery and pinching it beiween ihumb and
{oref,noer. l{ the source o{ bleedrng is beh no the oarcreas mdnJally
"ompr'"ss 
t're ent're pancreat;coduodenal complex Temoo'anLy
control bleeding fiom the hepaioduodenal ligament by 
pinching the
portal triad (Chapter 6)
3. fhe su?erticial laYer
consists of ihe iniured
pancreat icoduodenal
complex rtself. Injury io
the head of the
pancreas can be lhe
source of brisk bright_
red bleeding from the
pancreat icoduodenal
vessels, Here again,
ihe quickest way to
gam temPorary conrrcl
is a Kocher maneuver'
which enables You to
comPress the entire
pancreai icoduodenal
complex in Your hands
of encircle il with a
Penrose drain lo gei
temporary hemostasis
Some soul wounds bLeed {reely into the peritonealcavity' 
while others
DTesent as a conlarneo he_laroma Co'Irol o ' i 'ee bleeding 
comes t l rs l
Never ever 
'pote a skunk' by enrenrg a coniained hemaLomd unl i al l 1€e
bleeding has been controlled and you have organized your attack'
Supraceliac aortic clamping is a useful adjunct in a cfashing 
patient
Double clamping of bolh the supraceliac and infrarenal aorta 
(to control
backflow) helPs reduce bleeding Jrom iniuries to the superlof mesenlenc
vessels and the portalvein bui will nol dry up lhe operative field'
E ro, **,rr rn" o,i & croit of Tfoumo sursery
, 
All this seems nice and neat when siiijng at home readjng (of writing)
about ii. But the professional term for what you meet in real life is mulr.,tocal exsanguination, rapid bleeding from muhipte sources, none of them
easy to control. A less professionalterm is bloody mess, and you have nor/me to consutt www'broooymesc.org fo. aov.,e, roJ must starncn rhe
b/eeding NOW usrng a coF,binat io 'r of odck ng, the Kocrer mareuvel
manuat pressure, and careful clamDino
once you. have gain.a t"mpo*r; c*trot oi hemorrhage, stop ihe
operation and organize your attack on the injury. Don,t jusi dive tn wlihoul
appropflate Instruments, plenty of blood units if ihe OR, an auto-
t 'ansfus:on dFvtcp. a rapid,nfLser ool imdlexposu.e. ano comoetenr help.
r l 'eeorrg rro- d soul woJrd rdkes BtG IROUBLE {Chaptpr 2) to a rew
level - TREN4ENDOUS TROUBLE.
Soul wounds bleed from more than one vascular iniuru
Imptoving exposure
The key to anfhing you
may need to do around
ihe surgtcal soul is ihe
wrdesi possjbie Kocher
maneuver (Chapter 4).
For bleeding from the
deep layer ( lVC afd r ight
kidney), extend the
Kocher maneuver into a
ful l r ight-sided medial
vrsceral roiatron by mob-
iJizing the right colon and
retract the liver cephalad to create a wofk space around the pararefal
lVC. l f the r ight fenat hi tum is involved, mobi l iz ing the r ight k idney out of
Gerota's fascia afd rotating it medially helps you gain control of ihe
hi lum.
I The woLrnded SurgicolSou!
Use the Cattell_Braasch
maneuver (chapier 4) io obiain
lhe widest possible exposure oi
the sufgical soul This
maneuver uncovers the third
and fourth Parts ot the
duodenum, allows You to reach
ihe pfoximal SMA and SMV as
they emerge beneath ihe neck
of the pancreas, and even gives
you some access to ihe
relropancreat c ponal veLn
lJse the Cattell-Braasch maneuver to expose the surgical soul
The supraduodenal Portal vein
InjLiry to the supraduodenal Porialvein is usually associaied with a high_
orade iiver 'rju-y ano p'esFnls as a hematoma In the hepalodJodFnaL
ioament. The Do,Jble Pingte -aneuver rs the texlbook_recornmendpd- 
technique for de{inilive conlrol ol
injury to the portal triad, including
the suptaduodenal Portion of the
ponal vein. Begin with a Kocher
maneuver; then, coming from the
right hand side, Place one
vascular clamp irnmediatelY
above the upper border ot the
duodenum. Place a second
vascular clamp across the portal
iiad, as high as Possible ioward
the liver hilum. This allows You to
open ihe serosa of the hepato_
duodenal ligament and carefully
E ,o, *",rr rnu on & crofr of Troumo surgery
o.ssecl lo derile the iltury. UnfoaunarFty, lhe hFpatoduooenal
oner too shori to acuommoda,e two clamps. A good ahe.native
Ine InlL'ed ar€a wth yoJr,eJl ha'ld while dissecting dbove and
injury with your right.
A/ways assess all three elemefts of the portal tflad because their closeprox/mfiy makes ii very likely ihat more ihan ore siructure has been hit. Asiab iypically causes a clean laceration of the portal vein and js amenable
to a e'al repai l - contrast. gLnsho, .n,uies LaJSF Tasstve desiuciron
tusuarty rr coryunct ior wrth a. i rer i r 'ury1. reoLinlg a complFx repair s,ch
as a patch or rnterposjtion graft, which is rarely feasible in the harsh realiiy
ol multifocal exsanguinatron.
The oamage Lonro' soturon lof a como,er supraduodera, porat var '1
rr lJry. r lgar 'on. l t rs a real ist ic opt iol and co-pa. ibte w tr sJrv.va. i r therepalrc arteJ ts intacr. Wher bo.h porta, veir and hepatic anery a-e
rrlured, you have to reconstruct one of them
The retropancteatic vessels
InJunes to the retropancreatic vessels (the confluence of the superior
mesentenc and splenic vetns, as well as the reiropancrealic part of the
SMA) are particularly jethaj because you can,i get to them. pancreaijc
rfans-Aclon across the neck exposes these injuries. One of us finds this
technique useful and lifesaving, while the other avoids dividing the neck of
the pancreas unless the jnjury has done it for rrm.
To transect the pancreas, compress ihe breeorng pancreatrcoduodenal
complex with your left hand to temporarily control the bleedifg. Do a
co-.]pele Cafel-Braasuh maneLver ro oplimtzF acLess io the complex'rom al l s.des. Rapiory create a relropancrea, ic tun,rel oy opening tre
hepatodlodenai ligament and blunfly dissecting immediatety to rh; teft,
anterior to the common bile duct, and behind the pancreatic neck.
Transect the neck of the pancreas using ihe cautery over your finger, but
ligament is
is pinching
betow ihe
Ligation is the bail out solution for portslvein iniurv
8 rhe wounded surqicolsoul A
avord ot-shing Insfuments lc'amps or slaolPrs) inlo lhe 
lunnel because
t"." ,l^" 
""',rt"""," 
a retopancleai'c porta' vei'r 
'njJ'y Cudng rhe
""ri".""i 
u.i"n" v., tace-loJace with rhe 
iniu'ed ra'ge vein Lnde'nearl^'
Ii"^-t", ," 
"oo"n-',y 
to l:x i Conl'ol blFFd ng rror the eoges ol the
i"."""i*" p""f,"r. ror t'om adlacerr bleFde'sr onlv atter vou 
have
controlled the iniured podal vern.
It oossible, do a laleral 'epair o{ the retroparurealic veins However' 
d
you Jno up wiil_ a ligated {o/ oversew.]) porta' vFir a.ld a live oatierl' 
take
a deep breath and congratulate yoursefi
The root of the mesentery
While pinching the bleeding root of the mesentefy between thumb 
and
fore{inoe; lift th-e transverse colon cephalad and pull the small 
bowel
"-"J"tt"v "na 
to tn" r"t. rhis stretches the mesentery of ihe small bowel
va." jtr"n"u"r"" in"i"ion in the serosa of lhe root of the mesentery and
care{ully dissect in the mesenteric hematoma to find ihe SMA 
and SMV
de{ine ihe injury, and clamp Lt selectrvely'
lf ihe injury is immediately
below ihe Pancreatic border'
optimize your exposure b)/
mobilizing the ligament ol
Tfeilz or by doing a full
Cattell-Braasch maneuver'
The SMA is exPosed,
allowing you io Place YoLlr
clamps selectively. Never
clamp blindly at the root ol
ihe mesentery' t ls a reclpe
Transect the pancreas to gain accessto the podal vein confluence
. . ' l
..'. )a-.
E ,o, *",rr.n. on & croft of Tfoumo sursery
",,T:"J^:,#T" " 
*:. srvtA ;s di.cussed in rhe rerr chaorer. Repa,. rrerIU?o srMv rt yoJ cani i, nor. ,;gare :r. Fotlowing hgalron of Fither t1F portalvern or ihe SMV ihe jneviiable consequence js massive fluid sequestrationan^d midgut,edema, whjch translate into extremely high postoperative fiuiJrequrrements and an tnab/lity io close the aboomen, In iact, as we wrote
l,': :::o]L : l?l'*'" oLis w,rh d sou woJro u"a"*". svv ris;ri";.nrs vacLLr oac\ drdired ib i t j t t ters oi sero,rs t ,u;o fro_ rhe p"n-torea,cavty on lhe fjrsi posloperatjve day. Don,t forget that venous gangrene of
ll: T.y:i 
'" , oirr ncr rhrear. so atways oo a se.ond rook ."pa,o-romy roascedarn bowei viabitii!
_ 
The pancreaticoduodenal @mple., ..
Sorie of the most fascinating reading in the trauma literaiure describespdlcr.al icoduodena, reDair tech1,o,res, spalr tng d wide .anoF o, vervrmagr'rai ve resecirons ard recorstruci ons. We a.e oa.tjc-la.,y ioro o{ ihiopirmisttc ii ustraiion of both ends of a transected pancreas ptugged into aR-ou\+n-Y tooo ol oowe,. crFalirg rwo aojacenr oarcreattcolelJrostom es
il;"l'J;j"n,." 
lhe prinred pase -oterates ar,.rhins. lJnfon:rar"ty.
KFeo rhngs as s.-noe as ooss:b.e. €voto acrooaltcs. and st.ck to a,mrred -enu o, sraighifo,ward ooLons. yoL wih nor f ,1d d deta led
: l l_* ' t ] " . : ' " i 
possibte parcred, icoouooe' la, ,ecorsrrucr ive rechlrqLesrT lFrs chaoter lastead. we give you a ve.y | _i ted m€nJ of s:-p,e a.o sateIecnn.q,res thai wo-l ,or rs. T.ree ca-dr,ral orirciple" shoLto gLioe yorr
approach to proxjmal pancreatic and duodenal injuries:
1. Dfai . every suiure l ine in the duodenum and
pancreatic injury.
every signjficant
2. P.ov'de a roule for Fnlerar teeo:4q oslat to lhe duooenum, For n,tnor/rjufles. a raso,elLnaj rJbF rs an option. In _ajor 1a--a, a feedino
, JetLnoslomy provrdes a crlcal nutrtrorat sdfery va ve, for yo.:r patteri3. I\,lost rmoo.ranlty, r,hoose yor_r repat. tecnn,qJe oased noi on howwpt' ,r worhs, bui on how wert it /a,/s (CrapJe, l)
Blind clamping at the root of the mesentery is a recipe for disaster
Choose your repai based on how well it faxs
l
exlernally wlth a closed suction drain
8 The Woundecl SurgicolsouL
I t3,,1'4 rh
Duodenal injuries
Can vou close ihe injured duodenum wilhout iension? ln 
mosi cases'
a"ti"iii'i |'"p.i|. of a arodenal laceraijon is a,simple 
lateral suiure Just as
in small bowel injuries, orient your suiure line iransversely' 
even il the
laceration is longiiudinal, io avoid narrowing the lumen 
lf the lacerairon !s
tio iono,o 
""fli""" 
u u"nsverse repaif withoui tension' do a longiiudinal
,li"i. it" 
"rtur"t""lnique 
is a matter of personalpreference We usually
do a sinqle layer continuous repair in an inveriing fashion
Tne probleralic wounos are ins'de the duodonal 'oop on lhe 
pancrealic
aso"alt tt'" watL, wt "re 
precise visualization of the laceralion is difflcult
,qs in other situations where the injured posterior wall of a 
struciure rs
inaccessible, consrde'openi.1g lhe ouoderLm and teo,ai5g 
lhe i r iury
'ron rhe irs ide. u.$:- i ' r l '1)1 
'a n\aw ' t ! '1
-i-fl +r-- J^**- "'f - r'* )
Protecl any ouode.1ar reparr r\ar is 
-ore tnan a siraigl^torward sho'r
"riur" 
tin" 
"niit' " 
pytorl. 
"xclusion 
This is good advice fof suture lines that
aie tong, nlr l t iptL, delayed' or appear tenuous Sorne 
surgeons
decompies. duooenal repairs etne' by a aleral dJodenostomy 
or Dy
"""r t ' "n, 
-""g*0" trbe {rom i l 'e p 'o{ imal je j ' r1Lm as parl o{ a 3_IUbe
svs'em tnat also inclLdes a gastros+omy ano a fe"d ng 
jeiuroslomy We
n'." i ror, in"ru ao, *o" duoienosromy br ' ' we drair al 'duoo"nal 
-epai 's
What if the duodenum is nearly transecled? ln the 1si' 3rd 
and 4th
*rts. uo., .av Oe "Ore 
to ca'e{Llly debnde the duodenal war' to nea thy
;;"r;'"; t;"" do ar Fno-Io-end aiastomosrs w;th 
ihe verv r;-iled
mobility thai you have, it is easiest to begin sewing on the Pancreanc 
sLoe'
;;'ki.; t""; wav arouno the dJooenal circumlFrence 
trom wiLl'ir Ihe
trrn"n,-Ho*"u",, u" tt'" oLode.1a''oop' Ihe aohererce oi lhe 
pancreas and
the proximity of the ampulla usually preclude a duodenoduodenostorny'
The mosi versatlle reconstructive opiion for large duodenal 
defects rs
or i , rorrq up a RoL\-en_Y loop of ie jJnLf i lo repar lhe 
defpLt or lo re '
]"ru 'J i i "" . dr"o.t tu 'r1, xeeo i ' mi, .d ' nowevFr' a Rou/-er-Y'euorsirJcl ion
J,il"-"o*u.ins 
"td 
|."levant only in a stable patient with no other active
'"Lrr'.". 
-Si""" 
""""-. 
Oodenal trauma is almost always associated with
TOP XNIfE The Ari 8 Crolt of Troumo Surgery
other injuries, we use ihe Roux-ef-y technique mostly for delayed
reconstructronsj veTy rafety during ihe initial opefaiion.
L * N
There.are no good damage control opiions lor a bad injury rd rha 9nd
part of the duodenum. lf you need to bail our quickly, approximare the
edges of a large defect around an external drajn to convert the open
duodenur. Into a controlled Jisiula. Thls should be an absolulely lasi resoft,
since repairing the duodenal injLrry is always a much beiter option.
Repair inaccessible duodenal injuries from the inside
Pancreatic iniuries
What are the damage control options for injuries to the head of the
pancreas? For a non-bleeding injury, the quick and simple solution is
external drainage, converting even a major duct disrupiion into a controlled
pancreatrc Jistula that has a surprisingly befign natural course.
Bleeding from a proximal pancreatic injury requires careful assessment.
Once ihe pancreaiicoduodenal comptex has been mobilzed by a Kocher
maneuverj cofirol bleeding by local pressure, hemostatic sutures, or
packing. Unless the entrfe pancreaticoduodenal complex is shattered,
massive hemorrhage from a proximal pancreatic injury is always fronr an
undeiying major vascu ar njury.
Don t fiddle with the pancreast The classic teaching is to estab|sh the
presence ol a malor pancreatic duct injury. Reality is somewhat different.
lntraoperative examination ofthe lnjury wit setoom provroe an answer, and
you are aheady fanr i l iar with our lack of enthusiasm for oniable
pancrealography (Chaprer 7). The truth is thai it probabty doesn t matter
whether the duct is rnlured or not because external dralnage works well in
Don't fiddle with the pancreas - drain itl
8 The Wounded Surgico Sou
Those who like playing wilh dynamite adhefe to the traditional concept
of o'pservirq palcrealic tissLe Wnal ir amoJrls Io ls 
perfor-lrg a
o"r i"*" : ."1"1".*" .v on a 
' rormal pa,rc eal ic sl 'mp a Fig,r-rrs l
," . . , . .* i " ev.n J. ]Oer rne besi eleLl lve clrcunstarces Cons:de' 
'or
example, the options for lraciure of ihe neck of the pancreas' 
where fie
ot"na i" tr"n"""t"a by an anteroposterior inrpact against ihe 
splne The
iafest definitive option for this injury is closure oJ the proximal slurnp'
followod by resecting the disial pancreas or oversewing the open 
drstaL
st!mp. Analomical reconsiruction would mean debridement oi the 
stump
."1 i*ti"g a normal so{l pancreaiic remnani into a Roux_en'Y 
loop of
bowel, in ciose proximity to an oversewn pancreatic head and 
a bowel
suture line. lf this sou nds un safe to you ' we agree Wh ile enth 
usiastical y
described in texibooks and often discussed, current feports 
oi what
surqeons actually do (as opposed to what they talk about) indicate 
thls
"pplo".n 
i" u",v *t"rv used Apparenily, enough surgeons have learned
tie oainful lesson that {iddling with the vaumatized pancreas does 
not pay
We prefer io close the pancreaiic stump and drain ii
Avoid pancreaticoieiunostomy for trauma
Combined injuries
Bleeo,ng pai ienls with comor,red 
'niur ies to Ihe pancreas ard
a-oden.,m-oo _oI de tom a dLodenal eak lh€y ersangurrale So 
slop
the bleeding and bail oui l{ you can rapidly close ihe duodenum' 
do I
Otherwise, use a combination of external drainage andligaiion 
io conlrol
Juodenal, biliary, and pancreaiic conteni Relurn for a later reconstruction
if the paiient makes lt.
Pvloric exclusion ls an effective technique fot temporarily diverting 
the
qast'ric 
"ontent 
away {fonr the iniured pancfeaticoduodenal complex
i"ing e"yrot 
"rtg"on", 
nue have a bias toward ihis elegant procedure we
i""rnl"a tro. e"otg" l- -lordan, Jr', who conceived ii We advise 
using t
to oroteci duodenaisutute lines in combined pancrealicoduodenal 
injuries
where lhe duodenum can be closed and ihe ampulla is intact
TOP KNIFE The Ad & Craft of Trourno Surgery
After repairing the
duodenai injury, identify
the pylorus and make a
longitudinal gastrotomy
on the antefior surface
of the antrum, close to
ihe pylorus. Through
the gastrotomy, palpate
ihe pylor ic r ing with
your l rnger, gfasp i t
with a Babcock clanrp,
and pull it toward you.
Ovefsew the pyloric
ring with a heavy (size
0) suture on a large
needle, iaking big bites.
We lse a monofilament
suture, but regardless ofthe suture maierial, the pylorus opens in 2,4 weeks.
In fact, you can slaple acrossthe pylorus using a linear stapler with the same
result,
Once the pyJorus
is closed, br lng up a
loop of proxima
jelunum and do a
g a s t r o j e j u n o s t o m y .
The Jast siep in the
procedure is pfoviding
a route for enteral
Jeeding into ihe
jejunum. The operation
is noi ulcerogenic,
and vagoiomy is not
part ot it.
8 The Woundecl 5urg icol Soul
The Achilles heel of pyloric exclusion is ihe gastroenierostomy slnce 
Lt
cades a significant risk of nonJunction To avoid this 
probem' some
surgeons preJet lo do pyloric exclusion without gasiroenterostomy' 
relyrng
on distal enteral feeding uniil the pylorus opens
The "Ultimate Big Whack" ,vf-\
A vauma Whipple is tha ultimate big whack of abdominal trauma Use
it as a lasi resori when the pancreaticoduodenal complex is destroyed 
or
when the ampulla cannot be reconstrucied and no simpler solution 
will
work. ll is often said ihai you should consider a trauma Whipple 
when the
:n J1 l^as alreaoy done mosl of lhe d:ssecl ion 
ror you H€rein l ies 'he b g
nlrrao" ot rnis'operariol: tn" e{sangurnalirg paiierL wlh a snatterpd
i".l,".i""ar.o*a 
".rp'ex 
is Loo sick to curvrvF it A -tabre palient who
Jf .rru,u" n o{Ien does not need t so choose a lesser akernat 've'
however imperfeci, whenever you can'
Use pylodc exclusion to protect complicated duodenal suture lines
TOP KNTFE The Art & Croft of Troumo Slrgery
a
The three important differences between a Whipple for tfauma and a
lllllp,:,a' 
r,arcer ar": drssecring the Lnc,nare orocess. removrrg tnegaIo|adde., and staged reconskuclion,
During the resection siage for traurna, don,t dissect the uncjnaie
process otf the SMV and rhe SMA. Leave mosi of it adhefent to the
S[,lV by dividing it piecemeal and oversewing it wilh a runnjng stitch'or he-roslas,s as yoLr proceed. Th:s greaty srmpl.fres onF ot the
ticky sleps of the dlsseclior.
Think iwice before renroving ihe gallbladder in a trauma patieni. A fine
and delicaie common bile duct may force you to use the gallbladder
{orthe biliary,enteric reconshuciion.
The most important difference is that a trauma Whipple is a staged
procedure. During the jnitial damage control operation, achi-eve
hemosiasis and do the resection, noi the reconstrLrciion. Leave the
stomach, jejunum, and parcreatic stump stapled off. Leave the
common bile duct ligated or drained. At reoperation, perform the
arasta-oses, Except Jrder the mosr,avo,abt€ circumitances. wereave thF d srdl oancreatrc siumo slapled or ovFrsew.r and do ,rotjoin
it io the bowel (or 10 the stomach) io avoid a high-rjsk anastomosis in
a cdticallv ill oatient.
Putting it all together
We hope you realize by now why injuries 10 ihe surgicatsoutdeserve a
specral chapter. The sirategic drmension of a soul wound is
straightfoMard, sjnce it js preity obvious from the very beginning that you
must operate In damage conirol mode and dart oui of the belJy as quickJy
as you possrbiy can. The challenge of soul wounds lies in iheir tactical
complexity. You must simplify the taciical situation (Chapter t). Ask
yourself which elements of the problem can be rapidly ellminated. Look at
the deep layer of bleeding from the IVC and right renal pedicle. Do you
rear'y irte4d to do a como,er vasculdr reoair or rh,s bleedrng rena'pedicle
In the context of multifocal exsanguination? Of course noi. On ihe other
hand, a swft nephrectomy wijl open ihe way to the IVC intury.
a
a
lf forced to do a hauma Whippl€ - do it in stages
Are you going to hook the pancreatic stunrp to bowel as the 
patLent ls
*t ino'r l "-g+t i u,r i l o{ orood? YoL rust be kiodngl A raoid 
dislal
pu""r"""t"atotu howeve' may enabre you to reacn lFe 'eft side 
of Lhe
retropancf eatic Porial vein
These examples show you how io simpli{y lactical situations- Conslantly
ask yourself whal the simplest soluiion is for a specific inJUry 
- and go lor
il. The only hope lor a patient with a soul wound is a surgeon who 
ihinks
abour liqaiion, resection, drainage' and shunting 
_ noi about sprral vern
grafts aid Roux_en_Y pancreaiicojejunostomles'
E The wounded Surgicol soul
T H E K E Y P O I N T S
) Soul wounds bleed lrom more ihan one vascular 
injLlry'
) Use the Cattell_Braasch maneuver to expose 
the surgical soul
) Ligation is ihe bail oui soluiion for portalveln 
Inlury
> Transectihe pancreas lo gain access to 
the portalvein contluence
) Blind clamping at the root of ihe mesenlefy 
ls a recipe for disaster'
) Choose your repair based on how well 
it fails'
) Repair inaccessible duodenal injuries irom 
the inside
> Don' l f iddle with the pancreas'drain i t l
) Avoid pancreaticojelunostomy for trauma
Look for wavs to simplity the tactical situation
E ,o, *",rr rn. * & croft of Troumo sursery
) Use pyjoric exclusion to prot€ct complicated duod€nal suture lines.
) if forced to do a kauma Whippl€ - do it in stag€€.
) Look for ways to simplify the tacttcat situation.
Chapter 9
Big Red & Big Blue:
Abdominal Vascular Trauma
. . ,Lleon ?ntering !h? peiloneal .auit! , dpptoximalely 2lo
3 tit'erc ol blooi, bo!h liquid ond in (lols, Taere encounlerP'l
f i" ' , i"r" rcnloped. Thc bulle! pa!huaV ,uas- lhen.
idenlified as haoinB shdllereil the upPcr medial s tlo(? oJ
the ,ileen, then cntireil the refuoperitoneal area 7uh?te lherc
iii'o torB" rcttop?ritonPal hemalotna in the area of the
oanrreas.iollozuinp this, bleeding sccmed to be 
(ofiin3
'ftotn 
lhe right side,-an.l pon inspection lherc 'uas scPn Io'bi 
on r*it t'o th, ight throtgh the infeioroena 'aua lhe 'e
ihtouph the supe-rior pole-of the iSht |id e!, the louer
iiiiS, A the'right iobe oi th" liui' and into lhe riSht'lateflt 
b;du wilt'.. rn" infeior oena caua hole was
iiiip"a wiin a partial occlus1on clamp "' The inspection of
lhe ietroperitoical arca reuealetl a huge hcthdlomo in the
midline. fhe spleen uas lhen mobilized, as uas lhe I?J1
"ilon, 
ond the refuopeitonedl apPtotrch wtts fiade to the
iid-iirc structutes' The paflleas 7o4s seet to be shattered
i its mid portion, bleeiling uds seefl to be cotning ftotfi the
aorta.., B'leeiling was coitrolled by finger pressurc by D,r'
Moleolm O. Peiru Llpon iden!ifintion ol this iniury' the
suterior mesmteir artery ha.l beefi sheaftd olf the aorta"'
1ii. uas rla nped wilh a'sna I l (urucd DeBakey clam p' lhe
aotta was thin occluded Tnith a straight DeBdkey clanp
above and a Potts .lafip below. At this poinl all fiaior
bleedins was (o trol led.. ' Short lv thcrcafler" ' Ihe putse
role.., 
'was 
found lo bc 40 and a Iew sercnds later Joutld to
be zero. No'oulse was felt in the aoltd at this time'
- Opeiative Record oI Lee Ha|ve)' Oswald'
Parkland Memorial Ho spital 11' /24 /63
Cired n1t The \Nhren Commissian Repott: REart oJ the Presilent's
canmission an the Assas"^"." "f *zi,:i?::i',;X:,Til;
TOP KNIfE The Ari & Crofl ol Trourno Sugery
Operative Approach to Retropedtoneal Hematoma
No authorhas ever captured the tremendous challenge and 
un{orgiving
nature of abdominal vascular trauma better than ihis 
dry' technical
.".",i"" -pott 0""""t''q G To* Sn:res a,rd \is ream at 
Parl'aid do ng
i l rr t" * i , l 'nurpre vascLlar injJ- ies i ' l , le aodomer 
of Lee Hdrvey
O*"*"fa. ifr" *oon ".phasizes 
lhs centralleatures of abdominalvascular
trauma: massive bleeding irom inaccessible sites' 
muitiple assocated
';;,;""..;; un 
""u"."-tv 
narrow window of oppoduniiv to save the
.lil""i. v", noi onlv see the bleeding' bui vou can also 
often hear it
'Because 
the patient is exsanguinating, you rarely have lime io summon 
a
more experienced colLeague to help you gain control You 
have lo lasten
youf seat belt and gel going.
The "lules of engagement"
An abdomlnal vascular injury presenis as free iniraperl ioneal
hemorr l 'aqe, 'elropenlo'eal lematona o' n osl co-mo1ly ' 
a uombi lar 'on
o{ botn. In-e'rne'cas". i l s a 'ways BIG 
TROUBLE a'd ine key to sLuces"
;;;p"*ry control {ollowed by a well-organized atiack 
The location ol
the hematoma dictates the operalive approach
Hematoma Proximal
control
Explore?
PenetEling Blunt
Midline res
N4idline
looping
Distal aorta/
tvc
Yes SuPraceliac Matiox maneuver
Yss lnlrarenal Infrarenal aorijc
aoita or IVC exPosure or right_
sided visce€l rotat on
9 Big Red & Big BlLre: Abdominol Vasctr 
or rrourio H
Midline suPramesocolic hematoma
All midline sLrpfamesocolic
hemalomas must be exPlored lf
the patieni is in shock or if You see
rapid aclive hemorrhage from the
supramesocolic area, manuall)/
compress the supfacellac aona
(Chapter 2). lf ihe Patenl rs
hemodynamically siable, begrn
wlth the Maiiox maneuver' The
medialvisceral rctation allows you
to gain prcximal control of the
lowefthoracic aota bY cuiting the
lefi crus of the diaphragm
(Chapier 4). Always obtain dislaL
control above ihe aortic
bifurcation because without it,
considerable back bleeding will
Iniuries to ihe patavisceral aodic segment between the celiac and ihe
renaiarteries are highly lethal They are always associated with injuries 
io
"ii"l".t ".ort"t. 
'Blooo 
'o"" '" typicary -assive confo' is not
str 'a o'r forwarO, and repair reqJires sJptac€' iac ula-ping For al these
reasins, iry to get away with a laieral repair il you can'
l l vou mJsr sew n a sy1l l^eLrc 'nte-posi l io l g 'al t yoL are obvously
racino aaainst ine rela ' ischemic l ime' ano lhe oal ienr 's chances ot
n'akin'q iiare not sreai S-"lect a \,littFd Dacron g'ail lhalis cligl"tly 
latge'
ir,".,i" aon" a'i."*t oecaus" the aona ol a vou.lg oaliert rr shocl< 
r
vasoconstricied. Since you have no alternaiive, don t hesitate to 
put rn a
orafi even in the presence of intestinal sPillage Thefe are no enectLvo
iumaq" conror op ons fo- thesF 
'n;ur'es The patrenl s only hoPF s a
,- i . i " r i "+"" rapai 'of the aorta ano bai l out sout ions for associated
Inlunes.
Try to get away with lateral repair in suprarenal ao*ic iniuries
TOP KNIFE The Al-t & Crofl of Troumo Surgery
Pentrating trauma to ihe proximal fenal artery is essentially a side-hole
in the aorta. Initia control and exposure are the same as previously
described above. The realistic options for definilive repair or damage
conhol of the renal vessels were described jn Chapter 7.
Injury to lhe cel iac axis or l ts branches is uncommon, but deadly.
Typically, you see a gastric injury with either an expanding hematonra
behind the stomach of brisk aftefal bleeding from behind and above ihe
esser curve. This is one of ihe toughest and least advertised sltuations in
abdominaltrauma.
Wh le you car gain
proximal control of the
cel iac axis by rnedial
visceral roiation, this wil
not help yo! see or
control bleeding lrom its
branches. Furthermor-o,
the operal /ve circum-
siances may force you to
attack the bleeder fronf
the front. There are no
slandard prepackaged
solulions for this d tficuli
s i lLrat ion. A lechnique
that has worked for us is
inserting a gross hemo-
staiic stitch wiih a heavy
suture on a big needle (such as siz€ 0 polypropylene) into the lesser
omentum above the lesser curve of the stomach and suturing unti the
bleedjng stops.
A useful allernatlve is transeciing the stomach by firing a inear cuitng
siapler across the body, giving you immedlaie access to the vasculaf injury
behind ii. lf the patient suryives, complete the hemigask€ctomy ai
reoperation. Dissecting oui the origin of the celac axis, encased in a thick
layer of pefiaortic tissue, is not a realistic oplion in a bleedlng patient.
9 Bls Red & Bis Bluer AbdomjnoL vosculor lraur'o E|
IntLry Io tne p o\rmal SMA 15 anothe unlo-giv'ng 
s;t'iafon tnat prelpnis
," ' : ' ; : ; " " ; ' ; -" ' "col ic 
.ematomd An ir jLry to 
'he sMA dbove lhe
""*r"* 
J *""*'",'t 
"n 
anterior hole in the suprarenal aorta Control I
iror tt'" t"t 
"ia" 
Uy p"*orming a Mattox maneuver and clamplng the aorta
"0""" 
*J oa"* ,i" t"le-off o-f the vessel You can then get to the 
injured
SL4A, either from the side orfront, by making a hole in the lesser 
oment!m
and retracting the upper border of the pancreas caudally These 
injuries
are tvpicallv a=ssociated wiih damage lo the pancreas and adjacent 
bowel
Ott"'n your b""t option *ith a proximal SMA injufy is ligation' 
followed by
retrograde reconsiruction
Control of bleeding from the reiropancreauc SMA is 
achieved by
dividing the pancreas (Chapter 8) An injury to the SMA 
below ihe
parcre-as will manifest as a large her'atoma at the root of the mesentery
The damage control opiion for S[4A injuries is insert ng a 
tenrpofary
"lrnt. 
Wt it"i"" t'"u. not done it, others have reported it wofked {orthem
t ioari,rq t're proximal SIVIA i_ a sFverery hypotelsive ano vasoco,rslicted
p."t,"nt:. noi 
" 
gooa op ro' oecaJsF il lFaos 
-o bowel iscl-e-id So \ow
should you reconslruct lhe SIVIA?
The pinciples are lo use
the most exPedient method
and stay away from the injured
pancreas, because a €aKrng
pancteas and an anerlal
sulure l ine don t sr i welL
together To do a retrograde
reconsvuction from lhe infra'
mesocolic aorta, J/ou need
access to the side or to ihe
posierior aspect or tne
vessel, You can approacn fie
SIMA immediately below the
pancreas and frori the left b)/
dividing the liganrent of Treitz
and mobiLizing the four ih
portion of the duodenum.
TOP KNIFE Ihe Ad & Croft of Troumo Surgery
Alternativey, do a full Caiie lBraasch maneuver and reflect ihe small
bowel upward lo obtain good access to the posterior aspect of the SMA
lf you aie not sure how to do it, you can dissect out a more disial 
(and
therefore smaller) segment of the SlvlA at the base of the mesentery
Reconstruct the injured SIMA using a 6mm ringed ePTFE graft ftom the
distal aoria or the right com..on liac ariery LJsing the latter has
advantages: it does not require aodic clamping, is easy to cover wrh
omentum, and is technically staightlorward
Reconstruct the SMA away from the iniured pancreas
Midline inf ramesocolic hematoma
Eviscerate the small
bowel to the dght, Pull lhe
transverse colon uPward,
and take a good look ailhe
retroperiioneal hematoma
waiilng n the shadows ll
the bulk ofihe hemaioma is
to ihe Left of ihe small
bowel mesentery, You
probably are dealing wiih
an infrarenal aodic injury
thai can be approached
lhrough the midl ine l t ,
however, ihe hemator.a ls
more to the right, Pushing
on the ascending colon
lfonr behind, you probabLy are dealing wrth an IVC injury and
right-slded medial vlsceraL rotairon.
should do a
Aooroach an inlramesocolic aortic injury as you wouJd a ruplured aortic
aneurysm. lf you have tme, place a self'retaining retractor and ofganize
the o;erative field lo keep the bowel evisceraied and out of vour way The
9 Biq Red & Blg BIue: Abdomino VoscuLarrroumo 
g
classic pitfall ln proxirnal conirol
o{ lhe infrarenal aorla rs
iatrogenic iniury to the LRV or
lVC. To avoid ii, look at ihe
shape and Pfecise locatlon ol
the hematoma. lsii distal, away
from the root of the transverse
mesocolon? lf so' ihe 'sk ol
inadverieni injury to the LRV is
small. Mobilize ihe ligament of
Treiiz, refleci ihe fourth poriion
o{ the duodenum lalerally, and
enter the safe Pedaodic Plane'
Blunily cfeate a space lor a
clamp on boih sides oi the aorta
using Your {ingers However, if
the hematoma exlends higher uP
obscuring ihe ligament of Treilz'
it will be much safer io gain
supraceliac control ihrough the
Lesser omeniurn above the stomach, elther by man!ally 
compresslrg lne
".,t" "g"ln"t 
the spine or by clamping through the tighi crus ot the
diaphragm (Chapter 2).
Wlth proximal conirol in pLace' enter the hernatoma and' 
using blunt
ai"""iiiJn, 
".t"turrv 
oti"nt yourselJ to avoid the LRV Dlsseci distally in the
."r-""nt 
"f"* 
to a"tin"it'" injLrry' Reposition your clamps below the
i*Jlrt"r,"" to 
"onttot 
tfoublesome back bleeding from lhe distal aoria or
tom 'he lLmbar afe'es ard oeg n lhe reoa I
lJn{odunateLy, we cannot of{er you good damage conirol optlons 
lor the
infrarenal aorta either' We have lried inserting a chest iube 
as a lemporary
"tluniin ""t,"*" "irrutlons 
but did not have a survivor' However' in 1945'
C.i. Hotr", ot Cin"innuii brldged a large abdominal 
aortic de{eci {rom a
-eware of iahogenic vein injury in an inframesocolic hematoma
TOP KNIFE The Art & Crofl of Trourno surgery
gunshoi wound with a vltallium tube secured wiih umbilical iape The
patient survived and went home with the tube in place Anolher desperate
measure for extreme situaiions is oversewing ihe injured infrarenal aorta
and bilateralfasciotom es, followed by extra_anatomical revascu larizat on if
the paiieni survives the physiological insu t.
Whai are the definitive repair options? Unless the laceration is small
and amenable to simple lateral repair, your besi bel is io grab ihe bu I by
the horns and insert a short 14-18mm synthetc nterpositior gfaft Since
lhe aoria of healthy young paiients is smal and iears easily, at(empts lo
sew in a patch or do an end{o-end anastomosis olten ead io an
unsaiisfaciory result. We advise yoLr save yo!rself grief and go djfectly for
graft interposlion using knitted Dacron.
Always cover your inframesocolic vascular suture lines with omenium
Our preferred technique is lo lake down lhe greater omentum lrom the
tranverse colon along the bloodless line, create an opening in the
lransverse r.esocolon to the efi ol the midd e colc artery, and swing the
mobi ized omenlum through ihis hole into ihe inframesoco ic compartment
to cover ihe aortic reconsiruciior.
l f you see a bleeding hole in the psoas muscle, BEWAREI This
deceptive y simple lnjury ls one of those traps not mentioned in the books.
Whatevef you do, don't dig into the muscle in seafch of the source
B eeding in these cases ofien orig nates from the ascending umbar vein
or a lur.bar adery. Think of it uoi as a sma I bleeder inside a muscle, bui
asan naccessible sdehole in ihe aorta orthe lVC lnsiead of a direct
aitack, choose another hemostatic iechnique: stufi ihe hole wiih a local
hemostaiic agent, pui a balloon catheter into it, or pack t with gauze.
Whatevef you do - don t try to ideniify the bleeder' Your small bleeder wil
rapidly bloom into a ful-scale catastfophe.
Don't chase a bleeder into the psoas muscle
I8 ig Red & Big Blue: Abdtt t t 'ut ' t ' t ' ' ' t " t E
The Infedor Vena Cava
A large dark hematoma
behind ihe right colon is a
€ign o{ IVC iniury. This is a
unique sitllation in ttauma
surgery whefe you may
deliberately flip a control|ed
situation into unconirolled
calamity. The iamponade
ef{ect of the retroPeritoneurn
may have stopped rne
bleeding, and }/ou are going
lo unroof the injury and
release the tamPonade, with
a real risk of making thrngs
much worse. You betler be
absoluiely sure You Know
what you're doing
I
\
Prepare for BIG TROUBLE
(Chapter 2), and ihen unroot
the hemaioma bY right-sided
medial v isceral rotat ion.
Once you afe greeted with a
violent gllsh of dark blood,
gain temporary control oY
digi tal ly comPressing the
IVC againsi the splne aDove
and below the injurY. RaPidlY
delegate the iob to Your
assistani io free Your hands
fof the repair. Digilal Pressure
is effeciive, but the assistant's
hands limit Your worK sPace
We pteief to use t ighi lY
rol led laparotomy Pads held
on ringed clamps Watch ihe
TOP KNIFE The Art & Crofl of Trourno Sugery
palient's blood pressure on the monitor, and talk to the anesthesiologist lf
the patieni crashes wh le lhe lVC is being controlled, compress the aoria
as a hemodvnamic adiunct.
The key maneuver in
repairing large veins is to
define the edges ol rhe
laceration. lt js mpos-
sible to see the injury
propery wh le the IVC ls
actively bleeding. You are
looking for the edge of
the Laceralion - if not allo{
it, at east part of it. Look
for ihe s very intima and
genily gfasp the edge of
the laceraton with a ong
hemostat or a Babcock
clamp and lift it up to
visual ize the adjacent
segment. Apply another
clamp and hold it up too.
As you systematicaly work
your way around, you wlll
be ableto definethe entire circumfefence ofthe aceration and then control
it with one or two vascular clanrps. A side-bting Satinsky clamp is
particularly useful.
Another lrick is to insert a polypropylene suiure ai ether end of the
laceral ion and t ie i t whie your f inger occludes the hole. Gent ly pul ing
these end sutures caudad and cephalad, respectivey, pulls the edges of
the ve n iniury taut, like a rubber band or ihe sif ng oJ a fiddle. Moving youf
occ uding finger slowly allows you to place one suture at a tlrne in a
re atively bloodless field. Before you know lt, the repair is complete.
lf the IVC injury is posterior, inaccessibe, or there are several
laceraiions, delining ihe edges is much more difficult. When you can see
9 Blg Red & Big Bluei Abclomlnol vasculor lroumo 
g
tne b.€eoi'1g ']ole bui ca11ol delile the edge or cannot 
apoly d slde-bililg
clarp, 'n.e-rng a ld 'ge Folev catnercr rwi lh a 3omlbal loo,1r 
r '1 lo t \F lJmpn
and inflating it can helP.
A hematoma behind or above ihe duodenal loop should warn 
you ot a
caval injury around or above the renal veins lnserl a long Deaver 
retfactor
over the inferior surlace of the liver and iow ln to compress 
Ine
inaccessibLe supfarenal lVC, while simultaneously reiracting the liver 
10
or*ia" 
" 
fl.it"O wofk space Expose lhe right lateral and posterior
!"0""o oi tf'" pafarenal IVC by mobilizing the tighi kidney 
medially
Similarly, you can divide ihe proximal LRV wiih impuniiy to improve 
access
to ttre titt siae ot tle tVC. Ev€n with these maneuvers' conitol 
of the IVC
ai or above ihe renalveins is a real technlcal challenge
In IVC trauma, get hold of the wound edges
What are yout repair opiions? lf the laceraiion is straightforward 
and
easily accessible, do a latetal repair' lf ihe injury requlres a complex 
reparri
the patient is stable, and you have the necessary experience' 
you may be
rempled to e'gdge i l gymnast lcs Unlo4urately ' 
-hs favorab'e
""rno'- ,- . ' " "" .pf"" 
, r* f in i ' r 'y i r a stabre pal iel l wi lh no olher
iniuri"" i" 
"n 
extremely rare bird, almosi never seen in natufe A classic
eia.ple of gy.na.t 'c i , an r l lJsrrai ion yoJ of ien see in boons a1d 
at lases'
' " r"p; , oi , f ' " posier io 'wa' ol th. IVC fro- Ih€ Inside 
tn 'oJqh a
tonoiiudinal anierio, venotomy Nlany oiher neat complex reconstructive
t;;"iqr"" n"* been described for high-grade caval iniuries' 
including
Dane ora{'s, svnlhelrc grahs' palches ard n'ore Allbelorq to a bra"cn 
ol
i r ' r" i r* ." ' . t "*"* l ' " .w'r as scielce' icton Thev rdy nave worked 
fol
someone somewhere, bui ihey ate not going to wotk for you Our 
strong
advice - and we cannot ovefemphasize this enough 
' is to avoid the lancy
stu{f. lf you cannot do a simple lat€ral repaif on the inlrarenal IVC' 
ligate iiL
Do your besi to repair ihe activelybleeding suprarenalcava' 
but i{ the
oaient is,n exlremrs, consder a baloul solur lo ' Pacl ' 'ng 
may work _ l l
nas cerlainly wo-ked lo' us L:gat:on is a,rotl^er ootror' accept:ng 
that ihe
kidneys maytake a hii' which is stillfar betterlhan on_iable exsang!lnalon
TOP KNIFE The Ari & Croii oi Troumo Surgery
More importantly, if you see a non_expanding supfarenal henratoma below
the liver. do not touch it. Leave it alone ot pack it Don'i poke a skunk.
Ligate the IVC if lateral repair doesn't work
Pelvic hematoma
lJfless you specifically suspeci an iliac vascular inlury, do not oper a
pelvlc hematoma in a bluni ttauma patent wilh a pelvc lracture You w ll
only make matters wofse. lf you tind yourself Jacing a rupiured pelvc
hematoma in such a patient, your best move is to quickly pack the pe vis,
which shou d control venous bleeders. Fo low th s with a tapid ter.pofary
abdor. inaL cosure and proceed to angiography fof selectve embol izat ion
of aderial bLeeders, typ cally sma I branches of lhe iniernal liac arieties.
In a patient with penetrating
t|auma, a pelvLc nemaloma
means injury to an iiac vessel
unless proven otherwise. You
must unroof the lnjury and flx
it. lf the injury is on lhe right,
mobillze the cecum; lf on ihe
lef l , mobi l lze the s gnroid.
When you can t be sure and
suspect a bi lateral in juty,
doing a full Cattel-Braasch
maneuver grves you wde
exposure of the illac vesseLs
and keeps al l your opi ions
open, Now you musi gain
controL of the pelvlc vessels.
Pfoximal conirol is obviously
not enough. You maY have
forgotten the ntenral i iac
9 Big Recl & Big BLue: Abclomhol vosculor lralmo 
g
vessels, but they have not {orgotten you, and ihey afe difficult 
to reach So
what should You do?
The technica! PrinclPle is
"walking the clar iPs 
'
Begin with global control In
virgin terriiory outside ihe
hematoma by clamPing the
proximal common l l rac
artery iogeiher with ihe
underlying vein. The easiesl
way to achieve dLstal
conlrol is to have ] /ouf
assistani tow in wilh a large
Deaver retractor over the
lower part of the oPen
laparotomy wound, globally
compressing the exiernal
i l iac vessels wi ih ihe
reiracior against ihe Pubic
bone. Now, oPen the
poste-:or aodonila ot oelvic periloiFun' and o''l1lly d ss€ct w th yoLr
inoe, ro q"t Io ll'e lace atpd vessel As you progress i']sidF the
heilatoma, advance the clamps closer and closer to ihe iniury' applyrng
if'"r-a U.,i' iliac artery and vein lniiially, your conirol is 
global and
,"mot.. e" you gradually converge on the source of bleeding 
proximally
"nJ 
ilturrv,'vor i 
"rut 
ping becomes more seleciive Finallv' isolate and
controLthe internal iliac ariery or vein using an angled lascular cLamp' 
a
Satinksy side-biting clamp, an intralurninal Fogariy balloon' of any 
olher
method that works fof J/ou
Walking the clamps is a generallechnica princlple that applles in any
situation ihere an injured artery bifurcates and the deep branch is eithef
not oirec.tv v-be oi i raccessrb,e Conrro o"ne blFedi,rg 'e-ora'anery
" 
*" o'oi", td'oiid iri|.ries ir ihe lecl and pe,relralrrg lra'rma 
-o Lhe
tnorac; out lel are obvroLs examples wnerF wa ' ( 'ng 'he ula-ps can save
the day - and Your Patient's llfe
With irauma to the aortic or caval bifurcaiion or when you cannot be
sure which side is bleeding, you may have lo do a ioial pelvic vascular
TOP KNIFE lhe Art & CroJl ol Troumo Surgery
isolaiion. Begin wth the Cattell-Braasch maneuver to obiain ihe wdesi
possib e exposure of the pelvlc vasculature, then proceed wiih clamp ng
(or compressng) the disia aorta, and insert two Deaver retractors to
compress both dlstal exiefnal iliac arteres and veins. Now, enter the
hematoma afd start walking the clamps io converge on the inj!ries _ Jirsi
on one side and lhen on the other. Keep in nrind lhai the ureter passes
over the bilurcalion of the common iliac artery, and vour paiieni wi I do so
much better without a transected Lrreler.
Walk the clamps to gradually converge on an iliac iniury
Traunra io ihe confluence
ol the common i iac veins
is part cular ly dffcul t io
coniro because i t is
inaccessible, Lying beh nd
the r ight common l l iac
artery. Lf you cannot get to
i to inserl a hemostatc
suture, your besl move !s
to i ransect the overyrng
right common i iac adery
between clamps, giv ng
you access to the injured
conf luence. l f the pat ient
survives, repair the tran-
sected artery or Insert a
What are your repair optlons for the iLiac vessels? By the iime you have
gained vascllar control, ihe patient has iypicaly suffered riassve bood
oss and has associaied iniuries to olher abdomina otgans, usually ihe
co on. bladder or small bowel. Talk io the anesthesio og sl and assess lhe
magniiude of the physiological jnsult. More olten than noi, the siiuation wil
have damage contro wrltten alL over 1. lf the artety requ res on y a simple
l a l " ' a ' e p a ' - j - s _ o o i . . l f r h e i _ j u r y i s m o ' e e n e n s v p a t e - p o r c r y s l ' u 1 l
is a classic and effeciive ba I oui ootion.
9 Big Red & Big B ue: Abdominol Voscu or lroumo n
Anolher allernatlve ls to oversew the lniufed iliao a ery 
pedorm a
i"""i"i".V, 
""a 
*""f, ,le leg in the Surgical Intensive Care Unit (SlClJ)
lfthe patieni survives and the leg is grossly ischenric' do a femorojemoral
l*u"'" ior"a,or" p"*r"ion lf the patient is too u nstable even 
for a trip lo
iiJ on, ti'i" 
"t'uigttf.'*ard 
bvpass can be done ai the bedside in SlcU
it 
" 
togi"ti"" 
""ni" 
u iltLe demanding and the conditions awkward' but
the operation is feasible and we have done it Another uselul 
damage
contfol tech nique is to insed a Foley balloon catheter inio a bleeding 
bullet
tract deep in tire pelvis lo control hemoffhage lrom ihe iniernal 
lliac
ierriiory that is not accessible to direct control
As for definitive reconstruction of an injured iliac artery' our advrce 
s
not to wasie valuable tlme irying to mobilize a iransected artery 
ror an
end-to-end repair because i t rarely works lnstead' 
just Inierpose a
synthetic graft.
SpilLage of lniestinalconient is very cor.lmon in iliac vasculaftrauma 
and
po""s o dle --a b"car-e i r te" l i ' ra cor lel l a1d -yr lh"r ic grdtts a'e roi a
lood 
"o-on"ton 
Tl- is s n fdct sJch a oopuar qJPsl lo, t on Boa'd
ixams that you are lit<ely io encounier it there befofe you face the 
situation
in the OR.'Whal should you do? For lhe Board examiners' 
ihe safest
answ"r is ulso your sufest;piion: ligate the artery and do afemoro_{emoral
bvoass a{ter the abdomen is closed However' in real li{e we 
assess the
deqree of contamination For limited spillage of small bowel 
content' t Ls
..i to fix the bowel, nrigate the area, insert a synthetic interposition 
graft
and cover ii wth onrentum. lf the injufed iliac artery ls swimming 
In a pooL
lf fecal materlal, it doesn't iake a Google search to {igure out 
ihat ligaiion
with extra-anatomic bypass ls the only realistic oplion
Do not dilly-dally wiih iliac vein injuries They afe extremely unforgiving
and leihal. 1l iou have controlled the bleeding and 
youf paiient ls still alive'
uo, l"* ar*ay *"a up a pretty large chunk of good fortune 
Don t spoil
' "u"ru1n 
no 6v 6i1"rnpr ' .q compler 
-ep€i s l l yoL can l i / l , le inj- 'v wth a
., :0" 
" i " ' r f 
,epai ' . do i t . l { no' . ,gd.e tr-a vFir wi l r 'oLI a rno-enl 's
hesliation The iliac veins are nol mobile, so trying to close a 
large deteci
can put tne repair unaer tersion You find yo!rself replacing one small 
hole
wiih two larger ones. The nexi bite of the needle converis lhis 
into lour
S ,o, *n,r, ,n. on & croft or Troumo surgery
hol€s, and before you know it,1he game isover - you've lost. The gmartest
movs you can make is ligate lhe vein,
Shunting aRd li$lion ar€ the bail out options for iliac artery iniury
) Try to get away with lateral repair in suprarenal aortic injuri€s.
) Reconstruct the SIV1A away from lho injuredpancreas.
) Beware of iahogenic vein injury in an inframosocolic h€matoma,
.) . .Don't chase a bleeder into th€ psoas muscla.
). h NC tr.auma, g6t hold of the wound edges.
) Ligate the IVG if lat€ral r€pair doesn't.work.
) Wdk ihe clamps to gradually converge on an iliac injury
> Shunting and ligation are th€ bail out opiions for iliac art€ry injury.
Chapter 10
Double JeoPardY:
Thoracoabdominal Injuries
A battle is a Pheflorfienofl that alu)ays htkes
place ifi the i nctiorr between tTDo 'naps'
- AnonYmous Bdtish Officer' 1914
Where to go {irst - belly or chesi?
You are in ihe OR preparing to opefate on a 17_year_old kld in severe
shock. Hls story is very {amlliar: he was walking down ihe street mLndrng
his own business when two dudes approached and shoi him in the left
chesi. These same iwo dudes pop up fegularly on the stfeeis 
(especially
on weekend nighis), shooting people who always claim ihey were 
just
minding their o;n business Plain x'rays of ihe chest and abdomen show
a bullei in the epigastrium so, lhe buLlet went inio the Left chest' across
the diaphragm, and into ihe abdomen The chest iube you inseded on ihe
left is acliv;ly draining blood, while the abdomen is getting noiiceabLy
distended, and the blood pressure is plummeiing Where do you begin?
Chest or belly?
The clock ls ticking, and yout patieni is bleeding Belly or chest?
lf you are unsure where to begln, you are noi alone Some ot the mosi
exasperatlng baitles in trauma surgery occur in the iunction between the
abdomen and chest Duf lng training you are l ikely to hear about
thoracoabdominal iniuries at morbidily and mortallty conferences' bul
when you try to ook them up in trauma texts, you are in for a small
surpr ise. There is not a single chapter on thoracoabdominaltrauma in any
cur;ent major irauma iexlbook Why? What exactly are thoracoabdomrnal
injuries? Whai makes ihenr so special?
TOP KNIfE The Art & Croft of Troumo Surgery
A tour of no-man's land
The thoracoabdominal region, also known as the inhathoracic
abdomen, is a unique anatomical region. lt extends from the coslal margin
up to the nippie l;ne anteriorly, 6th intercostal space laterally, and the tip of
the scapula posteriorly. The region includes abdominal and thoracic
organs on both sides of the diaphragm.
Five visceral comparlments converge in the thoracoabdominal region:
the ghi and Ieft pleural spaces, mediasiinum, upper peritoneal cavity, and
upper retroperitoneum. While you are working in one compartment, lots of
mischief can occur in another, A common scenario has ihe surgeon and
eniire OR team focusing on the iniiiajly selected compartmeni while
neglecting the others. Rem6mber also, th6 abdominal side of the
thoracoabdominal region contains th€ leasi accessible portions of ihe
aorta, lVC, and upper Gl tract.
Five compartments converge in the thoracoabdominal region
lO DoubLe Jeopordv: Thorocoobdomino tr"*' E|
Strategic considerations
Approximately two'th tds of patienls with 
penetrating thoracoabdominal
,",rr|"; 
"t" "r**"t'V 
managed by chest tube drainaqe followed 
by
i.i;";; i;; bparoscopv) Roushlv one-ihird 
will need operative
iiiJ*""ii"'" l" notr', "r,"", 
and abdomen' and it is in these patients that 
the
traps awaii ]/ou
Thoracoabdominal injuries are ihe most comman 
lotn ol multicavitary
*""" l ; ; : ; ; " ; " ;e 
dearrs win b' |eeoins i r 
-ore Ihar one visceral
:l:ilu.:n;:":31,i^"L1".jlllifi;,""]ii";J##:iJiiT
"" 
IoL"" - r*gf, you have an assortment
* ' ,ala" p-" '"t gut wl_en tne patenl rs breeoilq 
lrom seve'al soLrces
"i."n.",1"*'r, 
you are not nearly as €fiective Why? Because 
lhe
;;";;joil;ii;Jt is sreatl;, accelerated 
Multiple soufces o{ bleedins
'*i: 
"im ;:ru.*" ", """"-"""1j lllfJJffi"::l"Ji: ij:
,r""t o' i"t ' , t '" th" ope'atve leld Lots ol worn 
to do: rol enough I 'ne
il J i. vo, .u"t O."lae very quickly io switch to damage 
contro mooe
How early can You make the decision?
You may be suPrised to
Learn that the trajeciory oJ
ihe bullet can help ]/ou make
an early decision to bail out
A bullei trajectory acro$ ihe
iruncal midline in a hYPo_
tensive Patieni ls a very
ominous sqn because ine
major neurovascular bundle
ol the human body (aorla'
vena cava, and splne) ls a
midline struciure Therefore,
the likelihood of a major
cardiovasculat injurY is high
and so is the modalrty A
trajectory across lne
TOP KNIFE The A.t & Crott of Troumo Surgery
ihoracoabdomina/ mid ne in a hypotensive patlent shoutd pui damage
control (and the possibility oJ a cardiac injury) foremost on your rnind, even
oelore you make the ncision. We cal a bullet trajectory across ihe iruncal
mldine a transaxial injury.
In a thoracoabdomtnal gunshoi injury, ihe bu lei has an /mporiant story
io tell, which is why surgeons with experence ir peneirating trauma obtain
a p aif film ofthe chest afd abdomen, if possjble, before going to the OR.
These radiographs, with metal markers placed adjaceft io eniry and exit
wounds, iellyou what to expect and guide you where io go.
Every bullet teils a story
Which cavity first?
Whe/r irying to decide whether io open the abdomen or chest frrst, you
face one of the classic diemmas of trauma surgery, and there aren t any
good rules to help you. Even with a lot oftraunra experience, you wlllbegin
with the /ess urgent cavrty in about oreihird of ihe cases, mainly because
the chest tube output is lrequently misleading. In some patients, the chesi
tube outpui actually feflects intfa-abdomina hemorrhage entering the
chest through a hole in the diaphragm. In others, a misplaced, kinked, or
nor{unctionrng chesi iube creales a {alse rrnpressiof that the patient is no
lofger bleeding. Here are some guidelires io help you decide where to go
a Be paranoid aboui chest iube ouiput, ii wi ofief ead you astray.
Assign a specifcteam memberto mon tof t throughout the operat ion.
a After chesi lube insertiof, get a chest x-ray in the ER to see if the
drained side of the chest has indeed been evacuated.
t Have a high ndex of susprcon for peficardtaltamponade.
a lJse focused ultrasoLrnd (FAST). Despite obvious Ilmitatlons, the
FAST exanrination wil ofien tellyou ifthere is a pericardialtampofade
or ots of blood in the belly.
a Play the odds. ln a right-sided ihoracoabdominal peneiration, the
mosi likely source of hemorrhage js ihe liver, so beginning with a
laparotomy is often a good decision.
lO Double Jeoparclv: Thorocoa bdomlnoL hr!r es El
The most impodant advice we can ofler you is to maintain 
lactLcal
*"lUi|',r". Si"l"t"" show that you will o{ien begin in one caviiy 
while the
main source of bleeding is in another' Recognize this fact and compensale
_o, i , u, o" i_q vigi lani ano rac.rca y l le/b' AuL'vely seFk cl res I l_al
so-" 'n ng susio ou. ,s ndpPen ng o' l lhe other s 'de ol Ih ' didp' tagm 
l ' re
a qraoLaJy pro'r t roi ' rg ,renioiapn ag oroore'srve'y obsuu'r '19 
your
ooe".a'ue'r . ld. A,ways oo p'epared ro cl 'arge yoJ'pra- rr 
' id_operator
a;d rapidLy dive into ihe other side of the diaphragm
Here again, good team leadership comes lnto play Talk io the
anesthesioLogisi Often a subiLe physlological derangemenl 
of
lnconsistenct ls the only clue that hemorrhage is ongoing on lhe other 
s de
o{ ihe diaphragm
clues to Bleeding on lhe Other side of the Diaphragm
Unexplained hYPotension
Inappropriaie response to lV fluids or blood
Graiuai in"reas" ln air*ay pressures (sign of a hemo/pneumoihorax)
Elevated central venous pressure (sign of lamponade)
Maintain tactical f lexibility
Peeking into the Pericardium
lf you suspecl a Perlcardia
ta..ponade during laParotomY,
ihe quickesi way io find oui rs
by doing a transdiaphragr.atic
peicardioiomy. Begin bY
d viding ihe lef t l r iang! lar
lgament io mobi l ize the lei l
lateral Lobe of ihe liver, whrch
usualy can be folded upon
ilsel{ and retracted to ihe
right. ldentify ihe diaphragm
in the mldline, anierior to the
TOP KNIFE lhe Art & Crof l of TroumoSLrrge./
EG junction, and grasp lt with lwo Allis cLamps Be careful not to iniure the
phrenic vein. Incise the diaphragm and the overlylng pericardium between
the Allis clamps unlil you see fluld escaping {rom lhe pericardial sac lf the
fluid is cleaf, close the hole wiih a heavy monofllamenl suture ll it is
bloody, pfoceed with either medlan sternotomy or lefl anlerior thoracotomy
(Chapter 1 1).
Mobilize the left lateral lobe for transdiaph.agmatic pericardiotomy
Fixing the diaphragm
Use laparoscopy io dlagnose a diaphragr.atic injury in asymptomaiic
patients wth thoracoabdominal penetraiions Lapafoscopy is an excellent
way lo look for iniuries io the left diaphragm or anterior portion ot the rLght
dlaphragm. l{ ihe paiient doesn't have a funciioning chest tube on the
relevant side, insufflating the belly may cause a tension pneumothorax if
there is a hole in lhe diaphragm. Therefote, prep and drape ihe chesi and
abdomen, and have a chest iube lnsertion klt ready before you begln
insuff lating the peritoneaL caviiy
Wiih an adequate pneumoperltoneLlm and the paiient t lted head up,
you have a nice view of ihe left side oJ ihe diaphragm and a partral
(anterior) view of ihe right. l{ ihere is a diaphragmtic iniury proceed with
explofaiory lapatotomy because you can t rely on laparoscopy 10 ru e ouT
a ho low organ injury Some surgeons repait lhe diaphragm
lapafoscopically if lhere has been an interval of several hours irom Lnjury
and ihe palient has remained asymptomatc.
Repair of an acuie diaphragmatic aceration s !sualy sttaighifo|ward'
lf ihere is a herniated organ ln the chest, reduce il' and see i{ ii is
perforaled. lf you are having diffcuLiy reducing the hernia' incise the
dlaphragm to enlarge the defect a Liitle to solve your ptoblem When you
are ready to cose the laceraiion, grab the edges with long Allis clamps
and pull ihem toward you. Use a cean sucker to evacuaie the pleural or
pericardial space above the injury Look at ihe effluent in the suctLon
lo Double Jeopordv: Thorocoabdomrnol hluies El
tubing, ls t clear or can
you iell what the Patient
had for supper? lt the
chest is heavily contam_
inaied, or f You are
evacuaiing lois of blood
and clot, formally open the
chest to address the
oleural space directly
Wilh heavy contamtnalpn
o{ the pLeuralspace, trying
to clean the hemiihorax
through the diaPhragmatic
defect is keyhole surgety
It is unsafe and ineffective
- don t do rt.
Close ihe diaphragmatic
laceration wrih a non_
absorbable heavy suture
We Lrse a running suture for
short lacerations and slmple
inierrupied suiures for long
ones. some surgeons preler
horizontal matlress sutures
or even a twolayer repair.
An impodani technical
principle is to leava the ends
oJ every suture long and use
them as handles io Pull lhe
diaphragmatic de{ect ioward
you. The edges ot a d|a_
ohraomatic de{ect tend io
,nue,i, so p.rffing o" Lhe last sntch wher placing lhe ne'l ore 
will l-elp you
^"t':""" oooo a'ppos'tron Take large oites Lo preven breedirg 
from t5e
pl'ren'c Jessers or ihe p eJra sioe of lhe diaol_raqm
TOP KNIFE The Aar & Croft ol Traurno Surgery
What if the defect is large and you cafnot approxlmate it wiih a simple
suture? lf the diaphragm s avLrlsed peripheraly, as sometimes seen in
severe bluni trauma, and the paiient is stable, you may be ab e to realtach
the avulsed diaphragm to a rib, usuaLly 1-2 ribs above the eveL of the
original avulsion. When reattachment s not an option and ihe defect is ioo
large for primary repair, a non-absorbable pfosihetic mesh is a quick and
easy sotulton,
lf you have to bail out or the operative field ls heavily contaminated,
reconstruciion with synthetic non-absorbabe mesh is not an oplion. While
there is no compelling reason to close a large diaphragmaiic defect when
operating in damage controlr.ode, failureto do so willlorce you to dealwlth
an even arger defect at reoperation. The muscular edges of the defeci
rapidly reiraci, progressively enlarglng ihe gap. Preventthis from happening
by insertrng an absorbable mesh as a temporary physica barrief between
the abdomen and chesl. At reoperaion, if the field is clean, the absorbable
mesh can be replaced by a permanenl non-absorbable prosthosls.
When fixing the diaphragm, pull it toward you
Opening Pandora's Box
Thirk iwice (and possibly
ihree times) before deciding
io mobi l ize the l iver in a
pai ieni with a thoraco-
abdom nal ifjury. You may be
blowing the ld off Pandora's
Box. A patient wiih a right-
sided thoracoabdominal injury
drain ng large amounts of
dark bood from a rnedia
hole in the d aphragm s l ikely
to have a retrohepatic venous
ifjury draining nto the chest
ihrough lhe diaphragmatic
defect. Going into the
lO Doube Jeopordy: Thoracoobdominol ","'t' 
E
abdomen to mobilize the liver and iix ihe hole from below is a lethal
mistake. lf indeed you are dealing with a coniained retrohepairc caval
rnrurv. lorl w J rose containment. converling lre slluallon inro unconi'o'led
venor,. h".orrh"g" Very rapidly you wi| i nd yoJrsell 
ttyirg to sqLeeTe
the toothpaste back into the tube
The correct approach is notio mobilizo the liver and stay wellawayfrom
the bare area. lnslead, return to ihe chesi and simply close the postenor
diaphragmatic hole with a couple of big siitches This simpl€ soLution will
re-establish containment, keep Pandora s Box closed, and prevent the
caiastrophic hemorrhage
Never open Pandora's Boxl
)
)
)
T H E K E Y P O I N T S
Five compaitments converge ln ihe thoracoabdominal region
Every bullet ie ls a story
Maintain iactical {lexibility
L4obilize the leit laieral lobe for tfansdiaphragmatic peticardiotomy
When -rxing lhe diaohrag-, pu I t loward you
Nev6r open Pandota's Boxl
TOP KNIfE The Ad a Crof l of Troumo Surgery
Chapter 11
The No-nonsense
Trauma ThoracotomY
Life is pleasaflt Death is peaceful
It's the fuansitiolr that's ttoublesome.
- Isaac Asimov
lmagine playing a new computer game The plot takes place In one or
more i tve do.ains o|. terrltories While you're erpLoring one domain' the
real action may well be unfolding in anothef' Each domain has a separate
portal, and choosing ihe wrong portal for a speciiic game lands you in deep
iroublefrom the get-go. To make things even more inter€sting, ihe game has
a different storyline in each terdiory. To top everythlng, your game rs last_
paced and short ' with no teplays
Beginning io think that you don't wani to play? Sorry' ii s noi a game'
and you have no choice lts thoracotomy for trauma, an operation that
olien starts as a good case and quickLy iurns into an operatlve roller
coasier, especlally if you are a general surgeon who does not frequenlly
visit the chesi. The action can unfold in one of more of iive separaie
viscefal compartments {two pleura! spaces' peticardial space' thoraclc
outLet, and posierior mediastinum), each accessible through a difiefent
incision. Several pathophysiological mechanisms may be at work
simultaneously: bleeding, hypoxia, catdiac lamponade' tension
pneumothorax, and air embolism, each evolving at a different pace Gei
the picture?
Where to cut?
Choosing the corfecl incision may well be your most important strategrc
decision jn a trauma ihofacoiomy. The wrong incision can turn a
siraightfoMard case into a technical nightmare'
TOP KNIFE The Arl & Crofi of Trourno Surgery
For the hemodynamicaly unstable patieni in need of a crash operation,
the utility incision is af arterolaterai thoracoiomy through the 4th
rntercostal space on the njured side. Ths quick incision keeps your
oplions open. You can easily exlend it across the sternum to the other side
of the chest or go into lhe abdomen wiihout having to reposition the
patient. However, flexib lity comes at a prce. Whle an anierolatera
thoracotomy allows you to get to all parts oJ the lpsilateral ung, trying to
reach a deep posteror chest wall bleeder or a posterior mediastinal
structure may be virlually impossible.For a penelrating wound to the rlghi lower chest with hemothorax,
consider going into ihe abdomen frst . The l iver dom naies ihe rght
thoracoabom nal reg on and is, therefore, the most ikely source o{ severe
hemorrhage (Chapier 10).
Begin with anterolateral thoracotomy in the unstable patient
[,/ed an sternoiomy is a good ncision for precordia] siab wounds, s nce
it gives yo! flll access to ihe heart and great vessels of the upper
mediasiirum. lts biggest advantage is extensibilrty; you can easily carry it
into the abdomen, neck, or along ihe clavicle. lt also provides access to
ihe hilum of each lung, but access to the per phery of the lung is resiricted,
and the oosterior mediastinum is naccessible.
In lhe patient aciively bleeding from penetratlng trauma to the thoracrc
outlei, you can stumble nto a big lrap if yo! choose lhe wrong incision.
You rnust base your decision on an educated guess as to the source of
hemorrhage. lf the patient presents in shock with a arge hemothorax, you
typically begin with the ltility anierolatera ihoracotomy but nray discover
you cannot repar the injury through this incision. You must thetr rapdly
extend t (or make a new one) to gel to the bleeder
lf the patieni is not aclively bleeding into ihe pleural space, median
sternoiomy is a good incislon for right-sided and midline thoracjc ouilet
wounds, giving you access io the rnnominaie artery and rts brarches,
However, it is difficull to get to ihe leit subcavan artery from the fronl
because the vessel is intrapleural and posterior So, in a patient with a
ll The No-nonsense Troumo Thorocorornv
penetraling injurY above ot
below the lett clavicle, gain
proximal control of the
subclavian adery ihrough a
high left anterolateraL
thoracoiomy in ihe 3rd
intercosial space (above
lhe nipple), recognizing
that you cannot f ix the
vessel through this very
llmited incision. You will
have to expose the lniured
subclavian artery through a
separaie incision (ChaPtef
1 3 ) .
The classic tfap door incision is a creative comblnation o{ a medran
sternotomy, left anterolatera ihoracotomy, and a lefl clavicuLar incision lt
requires forceful retraction to open the upper mediastinum and has a high
incldence of postoperative causalgialike pain due to siretching of ihe
brdLhal p 'e*us ard olher le 'ves We rpver uqe i l because you ca1
achieve the same exposure using jLlsitwo o{the ihree elements of the trap
door with much Less morbidity
Slable pat.€,lls hrde iewer surorises You ̂ 'row your sJ-gica iargel
iiom preopefative imaging, and this targei dictates your choice of incision
Extensibi l i ty into another visceraL compariment is usual ly not a
consrde-aton. Posleror medlasl i , ral s lruclLrF: sucn as lhe ao' la or
esophagus are approached through a posierolateral thoracotomy at a level
corresponding to the injury ln fact, poslerolatera lhoracolomy provrdes
such outstanJing exposure of the chesi wall, lung, and mediastinum that
one o{ us occasionaLly uses it in actively bleeding paiients, especially if the
peneiraling wound is posterior and low.
Caretully select your incision for thoracic outlet iniury
TOP KNIFE The Arl & Croft of lroumo Surgery
Anterolateral thoracotomy made easy
Place the patient supine with bolh arms exiended, and shove a roLled
sheet behind the scapula 1o siighily Jift and medially rotate the operated
side of ihe chest. A double- umen endolracheal tube rapidly placed by a
competent anesthesiologisl gives you a huge technical advantage.
Working around a collapsed lung is a walk in the park compared with the
iorture of trying to squeeze your way around a rhyihmically inJlating
Make a bold cui in
the 4th lntercosial
space, In a mae
paiient, this s below
ihe nipple. In a
female, retract the
breasi cranially and
make the incision in
the inframammary
Jold. Avoid the buk
of the pecloralis
major by placing the
incision immediately
below it.
Think of this operaiior as ihe thoracic equjvaleni of a crash aparotomy.
Work quickly and deliberaiely. This is not the time to be minimally invasivo
or go hunting for stray erythroc).tes with your thunder stick. lust grab a
kn fe and go into the chest. Carry your incision from lhe sterna border to
the midaxillary line, foLlowng the intercostal space in a sLight upward
curve. Laterally, you soon encounter the law of dim nishing returns: the
furlher you extend your inc sion, ihe rrlore muscle you have to cut w th less
An experienced surgeon eniers the chest with three bold strokes of the
knife: the Jirs l div ides lhe skin and subcutaneous tssue; the second cuts
through the pectoralis fascia, the pectoralis muscle anteriorly and the
serratus laterally; ihe thifd is a short incision in the intefcostal muscles that
brrngs you into the pleural space.
Grab a knife and dive into the chest
rr The No-nonsense TraLrmo rhorocotomv 
g
ib spreader carefully to create your work
lf necessary, extend Your
incision to the other side ofthe
chest by cutting across lhe
sternum cleanly using a Gigli
saw, an oscillating saw, or
bone cutters, When crossing
the stemum from left to right,
carry the incision uPwafd to
lhe 3rd intercosial sPace to
stay above the right niPPle,
thus iacilitaling exPosure ol the
upper mediastinal structurcs,
especially the innominaie
bifurcation.
anterolaiefal thofacotomy s failure to identify and
ends of ihe internal mammary arlery When the
and vasoconstricied, this deceitful artery seldom
Once you have cfeated a
window inio the P!eufal
space, feelfor any adheslons
beiween ihe lung and the
chest waLl. lf the way rs clear,
take a pair of heavy MaYo
scissors and boldly cut lhe
lntercostal muscLes along
your line of incision lnsert a
rib spreader inio the incision
wiih the handle ioward the
axilla; oiherwise, the handle
wi lL be in your way when You
try lo extend the incison
across ihe sternum, open lhe
The classic pidall in
ligate the transecied
patieni ls hypotensive
TOP KNIFE The Art & Croft of Troumo Surgery
bleeds. After you close the chest, it soon makes its presence known. lfyou
don t tie the ilansected ends, you guarantee your patient an early return to
the OR.
Don't forget the internal mammary artery because it won't forget you
Once inside the chest
ln most trauma thoracotorfies you will not have the befefrt of a double-
l!men iube, and the anesihesiologist will not be able to drop the lung upon
request. With the lung inflated, you in tialy see ltUe except a rh,,thmtca y
bulging balloon and blood arolnd ii. To explore ihe chest, you must
mobi l ize the lung.
The key maneuver is
cutting the inferior pulm-
onary ligamelrt. Gently
place your non-dominant
hand below the lower
lobe of the lung, pul l i t
cranial ly to put the nJerior
p! monary r gament on
tension, and divide i t with
scissors, Remember that
ihe ligameni ends at the
in{erior pulmonaryvein, and
a lacerated pulr.onary vein
may bring your operaiion io a speciacular premature end. Now, you can
retraci the ung and wofk around i i .
Mobilize the Iung by cutting the inferior pulmonary ligament
Evacuate the blood, ask the aneslhesiologist to stop inflating ihe l!ng
for a rnoment, and rapidly assess the situation. Where is the bleedrng
coming from? Lufg or chest wall? Do you suspeci a perlcardial
ll The No-nonsense Troumo rho'ocotomv 
g
umoonade? ls there a mediastinal hematorna? Brighi fed blood 
pooling in
iie'chesi is frequenily from chest wall bleeders, whereas a mixture 
of
blood and bubbles usually comes from lhe lung Gushes of dark blood are
the hallmark of a pulmonary hilar iniury' Mediastinal hematoma indicates
potenl.al |a 9e vesse'rr iury. A burqing telsP pe icaroiJm is a 
lamponade
r.rntil proven otherwise. Oblain iemporary control oJ bleeding by pack ng
the chesi wall, manually comPressing the pulnronary hilum of a massvely
bleeding lung, or opening lhe pericardium to release a tamponade' Once
vou have temporary conlrol of hemoffhage' decide whether 
you are
lealing wiih BIG TROUBLE or a small problem(Chapier 2)
Are you worried aboui the other side of ihe chest? You certainly should
be because you cannot see ii Any doubts aboul bleeding ln the olher
pleural space (eg suspicious trajectory or unexplained hypotension)
should prompi you to push your hand immediately anterior to the
poricardium lo creale a window inio the olher hemithorax ls blood pounng
out of your window? Can you scoop up blood and clots when you 
push
your hand into ihe lateral recesses of the pLeural space? lf so' you riust
explore ihe olher srde
Nexi, opiimize your work space ls your incision adequate or do you
need beiier exposure? Using bone cutiers, you can divide the costal
cartilage o{ ihe 4th rib at the upper edge of your incision to allow the tib
spreader to open wider' l{ time is criiical, open ihe ib spfeader as much
as you have io, even if you feel a rib cracking This ls not an eective
iho;acolomy, and you must have adequaie exposure, whatever it takes li
all thjs is siiil not enaugh, the ace up your sleeve is, ol course' a clam_shell
e,(renq'or ac'oss the slFrnurn Ihdr wlll exoose evFrylh'ng lt rs l_oweve- dn
incislon ihai carries significant rnorbidiiy
You may wish to do something aboui the lung ihat is rhythmically
billowing i; your face You can ask ihe anesthesiologisi to reduce ihe tida
volume io enable you to work around the lung, or you can help 
push the
endoiracheal iube into tha contralateral bronchus This 
'mainstemnring' is
mrcl_ easer on the nglt atnough lhe dgl^I Lpoer looe may'emain'o '_
ventilated. On the left slde, i is difficuli to blindly push the tube lnto ihe
n'ainstem bronchus Ercnangilg ar endo tt achear llbe {or a ooLble_lu-en
TOP KNIfE The Arl & Croft of Troumo Surgery
tube n m d'operation is difiicult and dangerous. Consider it wiih much
apprehension and only if nothing else works.
Optimize your work space and drop the lung il you can
Opening the pericardium
A classic errof of inexperience is leaving the pericardium unopened
becalse ii looks okay from the outside. Wth ihe pericardium, what you
see is noi what you get, and a normal appearirig sac can easily hide a
iamponade. Dlring a lefi anierolateral thoracotomy, retraci ihe left llng
posteriorly io expose the
lelt laiefal aspect of the
pericardium. Pinch it with
your lingerc to tent il up
and make a nick wi ih
scrssors anienof to the
phrenic nerve. lf you see
blood drainlng through ihe
hole, widely open ihe
pe,cardium by sl id ing the
s ighi ly open scissors
paral lel io the phren c
nerve, and deLiver the heart
into the open chesl.
lf you fnd blood in the pericardial sac during a right antefolateral
thoracotomy, immediately exiend inlo a clam-shell incision. You cannot
properly examine or flx the injured hearl from the righi side.
The closed pericardium is an enigma - open it!
1r T. e No no e-.F i 'oJ1 o 
-ho,o.otol v El
Conholling the PulmonarY hilum
Massive bleeding from a central lung injury requires swift control 
of the
hifu..-ftiht. 
"t"tping 
is a 'doomsday weapon' because it is poorly
tor"rut"a fy 
" 
put,.niin 
"hock 
l{ you can stoP the bleeding by any other
a""n", 
"u"f' 
^" a"*"f pressure, hemostatic sutufe' or rapid reseciion of
ihe injured segment - dont clamp the hilum
You can't even begin
to encircle lhe hi lum
unless the lung is
mobi l ized bY cutt ing
lhe inferior pulmonarY
ligamenl. Ask ihe anes-
ihesiologisi io stoP
vent i lat ing the lungs
momentarily, and gaiher
the part ial lY- inf lated
lung in ) /our non_
domlnant hand l ike a
bouquet o{ f lowers
Negotiate a Satinsky
clai,p arouno tne eni're hi'um laking cate 1o avoid Inrury to tne 
pn'eri!
""."J, 
*li"f' :s ararmilgly c,os6 Pulmora'v hilar Lla-1Ping requrres bolh
luna"; on. f'"na loldsl'ne open clamp while the other guides the 
jaws
around the hilum.
Clamping the hi lum
within the festricted work
space provided bY an
anterolaleral ihof acotomY
can be tricky because You
often cannoi see whai J/otl
are doing. There is a
sinrpler way to do it You
can tlvist ihe lung around
the hilum - ihe Pulmonary
hilar twist. Insiead ol
trying lo negotiate an
TOP KNIfE The Ad a Crofi ol Troumo Surgery
open c amp around the hilum, simply grab the mobiljzed lung with both
hands, holding ihe apex of the upper lobe and bas6 of the ower. Now,
twrst the lung 180' so that the apex of ihe upper lobe abuts ihe diaphragm
and lhe base of the lung is now where the apex fesrded until a few
seconds ago. Bleeding siops inrmediately. You may need to place a
laparotomy pad in the uppor pleural space io keep the lung in ihe ups de-
down poslton. This quck and simple maneuver is part icularly uselu
during ER thoracotomy, where exposure and workng condii ions are
severelV comprorlrised,
Twist the lung to rapidly control the hilum without a clamp
Aortic clamping
The descending thoracic aorta s flaccid and pulseless, easiy mistaken
lor an adjacent llaccid pulseess tube, the esophagus. Clamping lhe
esophagus does not improve the palient s hemodynamics one bit.
Placing a camp on the descend ng thoracc aorta during an urgent
anterolateral thoracotomy is guided mostly by palpation rather than direct
vision. Relract the left lung anteriory and s ide your hand on ihe posteror
chest wa lfrom lateral to medial, fee|ng the concavty of the posteror ribs
as they arch toward the sp ne. The first tubular siructure you feel aga nst
the i p of your fingers is the aorta. You can eiiher manually compress ii
agarnst the spine or place an aortic clamp across it freeing your hand for
The key to succ-
essfu clamping is io
open ihe panetal
pleura. lf the media-
stinalpeura overlyrng
the aoria remarns
Intact, your clamp will
slide off and wiihout
obtaining a purchas,"
I I The No nonsense TraLrm. Tltt'.]t"t.trtv 
gI
Make a hole in the parietal pleura on both sides of the aoda' 
ellher w th
vour I nop. o ' N4dvo ccis\ors. A ' yo- 'eFo 
is a r im reo ooe r i ' rg usr eloLgh
io.c.o'mmooaLe, cta-p o'r eac'r q de o' tnF lrac' d tJbe MoreF^lersi{"
dlsseclion may avulse an intercosia vesselor irjure ihe aorta itse f' 
making
maiiers much worse
The "turbo" version
The turbo version of a thoracotomy for iraur'a is ihe much adveltised ER
(or resuscitative) thoracotomy, a heroic operailon tvp cally begun in the
shock room but, l{ successfu, aways concuded in the OR' To b-'gin 
a
resuscitailve thoracotomy, a you need is an endoiracheal tlbe in 
place' a
steady hand, a decent kn fe, and a brarn In geaf
TLlh "ooucl 
Ihe pdl ie_- ' " t l ar- o gel t o ' r l o i yoJ- $av na'e
,o-eor. rqu ' t od ne on ro lF L ' , les- a_d -_'r ' cui l i_g W're Jei-yis
not a central issue her€, your safeiy is Sharp instr!ments and needles are
promlnenily in play during resusciiative thoracotonry A cardrna ruLe'
iheretore, is to have onlv one par o{ hands in ihe operauve f ield 
yours'
AccideniaL siicks and cuis are a clear and Presenl danger In lhe organrzed
chaos ol a resuscltalive ihoracotomy, and paiients w th penetrat ng trauma
often carry transmisslble diseases Don t klll yourself or injure a co league
whiLe trying to save Your Patleni
Resuscitaiive ihoracoiomy is a classic damage coniroL procedure Atter
you open ihe chesi, only f ive maneuvers are done in the ER
The Five lMoves of ER Thoracotomy
lncise the inferior pulmonary ligament to mobilize the lung
Open the pericardium and slaple (or sutufe) a cardiac laceraiion
Perform open cardlac massage
Clarnp the pulmonary hilum or twist a massively bleeding lung
Clamp the thoraclc aofia
You can't clamp the aorta over intact parietal pleufa
TOP KNIFE The Art E Crofl of TroL,rno Surgery
lf the palieni survives, do everyihing else in the OR. lf oroanized
Fleci l icar activiy does not retLrn w hin a reasoraole oeiod; i ime.
recognize failure and stop. Don t endanger your team in futile situations.
Regardless of your s!rgical talents and experience, you wlll not have many
survivors of resuscitative thoracoiomy.
Worry about personal and t€am safety in a resuscitative thoracotomyMedian stelnotomy
Make a vertical rncision if the
sternal r.idllne exiending from
2cm above the siernal noich to
3-4cm below the xiphold.
Deepen your. incisio. io the
anterior iable of ihe slernum,
keepir ,g to the midl ine. Def ine
the superior border of ihe
manubrium and blunl ly develop
the retrosternal plane from above
with your finger. Then, go to ihe
nfer iof part of your i rc is ion and
open the I nea alba lmmediate y
caudal to the xiphold io bluntly
develop ihe same plane from
Ask the anesthesiologist io stop
ventilating momentarily, divde the
siernunr in the midl ine using a
vertical sternal saw. Hook the toe
of the saw beneath ihe siernum
and pullon ii io elevate the bone as
it is be ng cui to reduce the risk of
iatrogen c injury to substernal
siructures. Use the cautery to
con?ol oozing from ihe cut edges
of the bone. lnseri a sternal
r The No-nonsense Trouma Thorocoiomv El
retractof and graduallY oPen
it wiihoui cracking the
What You are looking lor rs
ihe left innorninate veln, lne
gatekeeper oJ the ihoracic
ouilei. Exiending across the
anterior aspect ol the upPer
mediasiinum, it is lhe lrrsl
structure You have to deal
wiih when dissecting rn the
thoracic outlei ln the trauma
sltuat ion, ident i fy, c lamP,
divide, and ligate the vein
. |"ft in-.in"t" u"in is the gatekeeper of the upper 
mediastinum
Closing the chest
Much like lrauma laparotomy, you have to choose 
beiween de{initive
"nJ 
t".por"ry 
"to"r," 
o{ the chest ln eilhef case' place chest lubes 
In
r"^ 
"nerated 
oleurar space or ir tne medrastinum ano irspecl 
lhe cl_est
wa', carefrrly io' nrercostal mJscLlar' and rlernal 
Tammarv bl'eoFrs
When should you consider temporary closure? 
lt is a valid optlon when
,"" ; ; ; "1"; ;n" '" t ' the patenl s raoidrv 
oete' iorat 'ns ohvsio'ogv or
i^,i- *, 
",!"a 
a rerurn to thp cl'esl to re'novF pacrs or 
pe'{o-m
".*,t',1" 
r""^'*. Tempora'y closure or 
'ne cnesl means app-oxlmat ng
"" i" 
t t " 
" |< '" 
to achieve ai- i rgnt cosure 'eav ng t ,re ' ibs dnd 
Lhesl wal
.rl"i"" ,""oor*^""a You" can rapidly close 
the skin edges with eiiher
" """ti**" 
fl"*y .*o{ilament suiure or a series o{ towel 
clips Rarely'
wien the heart is swollen and edematous and will 
noi allow even skrn
"ll",rr" 
ot 
" 
."di"n 
"te'notomy 
nclsion' we iempotarily suture an emPty
r i""""""" r i r ia bag lo the ;k in edges,whi le 
the underly ing sternum
,"."in" oo"n This L ihe thoracic equivaleni 
of the plastic bag closure
described in Chapter 4
E ro, *",rr,n" on & crqft of Troumo su,sery
Skin-only closure of an anterolaieral ihoracotomy has one bigdrawbacl: i, brFeds Wh,Je rraking rhe ;rcrs,on, you ryprcalry ojvrde a
sLDslart tat mass of chest wah muscles in rhe rateralpa.r ol tne rncisror. l f
you don't approximate this m!scle mass, you will have coniinuous oozino
111-l"l ]'Tq" 
inio significani ongoing btood toss, especia y ii thlparent rs coagutopathic.
. 
Formal closure of an anteroJateral ihoracotomy is straighifoMard.
1ll.:: T,":: 
tl" '* usins rs6yy e"r,"o","| su,u.es tor,owed oy rayeredcrosLre ot the chesr wdl l rLscres, lascta and skin, h c,osing a c,am-s\el ,
li"llir'J;1,,5i?il" 
*'e to preciserv reapproximate the djvided sternum
T H E K E Y P O I N T S
) Begin with a/.rierolaterat ihoracotomy in the unstabte patient.
) Carefully setect your incision for thoracrc ouuet injury.
) Grab a knife and dive inio the chest.
) Don't fofget the jnternal mammary artery because it won,t forget you.
) Mobilize ihe lung by cutting rhe inferior putmonary tigamenr.
) Optimize your work space and drop the Jung ri you can.
) The closed pericardium is an enigma - open rl
) Twist the lung to rapidly control the hllum wthout a ctamp.
> You can't clamp the aorta over intact panetat pleura.
) Worry about personal and team safety in a reslscilatrve thoracotomy.
) The lefi jnnominate vein js the gatekeeper of the upper mediastinum.
Chapter L2
The Chest: Inside and Out
Good iudgmelll cofies t'rcm e'perteflce'
i, prri ir"i, o t 
" 
f 'o ttl Poor i u dgne n I'
- Arthur C. Beall Jr', MD
You are inside the righi chest doing a thoracoiomy 
for a gunshol injury
'" ;: il;';;;;;";t You a'e rerreved ro see 
the rLns is .,'oi br'edi's'
il,.it '"iit* '" -' rs lrom tne bullel l-olc 
in tl^e chesl wal" P'obabrv
i"i ". ",","""t" """,y. 
ll roo(s ke a,si.nple p,'""".r""1j::i,"""j#"ri;^:
hemostanc sttch Then' as you ky to gel to 
rr
1"."""J" 1""""""" oehi;d the diaphragm' 
it gradually dawns on you '
ihings are far ffom simPle
Wiih the lung rh}thmically billowing in your 
{ace' you can barely see ihe
or""l". iu"" ,itou ao' getting lo it through 
an anterolatefal thoracolomy
ni",ni ""."tri'* 
i.pos-srure Wnen vou rinattvfl""t?iJilJ ['il1i:
a frgure of I stltch, you discover you cann(
n"""d'" b"""r"" yo, k""o bu-p:ng rrlo 'bs 
lhe ilrercoslal -pace rs lu5r
;;;l; 
";;;"'; """"m'odate 
a rul' swins ol Ir'e reedle Welcome to
the big leaguesl
You have just come across a notoriously underrated 
iniury _ one ot the
"lial"n .on"t"r"" of traurna surgery lt is certainly 
not the only one
;;ffi il";;, " i*i "f :*ti";";1"*:"ry"13i$,:1,",,i,:lfilf;
(Chapter 5), a bleeding hole in ihe psoas n
i;;; i" ;i" rower extremitv ":::"]:.:"1'1" 1""il:"".i:i::l"j ;;#:1good "xd-pl€s TheJ a'e not"t o'_T1:'."-1ldo.*,d ar ri,sr grarue. Bur
to lhe surqical soul and may seem slralgl
*nl" r", iru. *". - yo'r discover 
you-a'e in deeper waters than you
thouq,1t, somotime. wel, over yoJ'heao The 
l^idder mo'1slert o{ Lrauma
,uil"orl oo",a,t" "'"",iv;ty 
ano imag;narol {orcing yotr lo Lome up w ln
unorthodox solutions
TOP KNIFE The Art & Croft of Trourro Surgery
Bleeding from the chest wall
, 
The intercostal and internal maramary arteries bleed furiously because
lhey have a bidirectional blood supply. To achieve etfeclive hemosiasis.
yoL mJsl conlror tne artery t-om botn s,des. The cnalrenging chesi watio'eeoer,'s not tl.e one localed -maoiatelv benFath your ;clio^ s.a,,.g
you n lne'ace wher you open the chest. h is the cunlrrg. Lnreachab,e
Injury, very high or very /ow on the cheet wall _ a bJeeder you can bareJv
Your frrst priorrty is temporary control. Raproty assess the situation: car
you see the spurting vessel? Are you dealing with a discrete arterv (rn
pererrating trauma) or wrt" d,f,use oozrlg f.om extensrve traLma to ciest
wall muscles (in blunt trauma)? Are the adjacent ribs fractured? ls ihere
more lra'r one sou.ca or b eedirg? Depeloing o.r yor,r, indr1g.. co_p.ess
tne oreeder w.tl your .inger, clanp ii, or tempora.'ty pack ir.
Next, opt imize your
exposure. lf the bleeder is
very low or very high on the .---
chest wall, you may have io
maKe a new tower (or
higher) incision to get io it.
A n€at trick is to move two
intercostal spaces up or
down through the same skin
incision and re-enter ihe
chesi through a more
appropnate rmercosla space,
g ving yourself a better shoi
at conirolling the injury. In
some cases you may need a
Now, choose an appropriate hemostatic technrque. lf the bleedino
vessel is r ighrin front of yoL. s,r1py ctamp a,ro sr,rure-. igate rt. Th:si,
usually possible with the internal mammary artery because ii runs
perpendicular to ihe ribs and is relatively easy to reach in its anterior
locatron. A transected intercostal artery js more chailengjng. lt often
l2 The Chesi: Inside ond Ouf
iniercosta rnusces and requ res aretracls in belween the surrounding
blind hemoslatic figure of I suture.
The secrel of success
is noi only choosing ihe
correcl needle stze, but
also orienting the needle
paih to be paralle - not
perpendicular to the
adiacent ribs. There is noi
enough space between
the ribs to accommodate
a fu I perpendicular swirg
of a large neede, so
unless you drive the
need e parallel to the ribs
you won t be able io
complete ihe arc and
extract it.
What should you do if the henrostatc siitch doesn t work? Hefe, a little
tactical creativity can go a lorrg way. Consider using hemostatic metal
c ips. Alternaiively,if the mnedlaiely adjaceni rib is shattered irio several
fragments, rapidly resectlng a fragment adjacent to the bleeding vesse
can give you valuable space for r.aneuvering.
lf all else lails, take a
heavy monof ameni sutlre
on a large needle and
encircle the ent ire r ib
inrmediaiely cephalad to the
bleeding ntercostal vessel,
igaling the neurovascular
bundle en masse and
compressing it against the
rib. Do it both proximal and
dislal to the bleedlng siie.
Postoperalive intercosial
nelralgia is an acceptable
prlce for this l i fesaving
)"'
TOP KNIFE The Ad & Crafi of Troumo Surgery
Another last resort technique thal works with large bleeding craters
trom high caliber glnshots rs baloon tamponade. Insert a arqe Folev
bal lool carheter lhrougr ihe niss, 'e racr f .or oJlside i r-o the ch"sL,
nflate the balloon, and pull hard to tamponade the bteeding. Ctamp ihe
Foley flush with the chest wall to maintain iraction on ihe catheier, and
suture the clamp to the skin to preveni accidental dislodgment. Leave th s
compressing balloon in place for a few days to ensure thrombosis of the
iniured artery. We have also stuffed bleeding bullet tracts in the deep
posterior chest wallwith local hemostatic agents or bone wax, much like
we do wi ih the hosing ver iebralar iery in the neck (Chapter j4).
A most ffustrating situaiion is diffuse multifocal oozrng fronr extensive
damage to the chest wall, wiih mu t ple assoc ated rib fractures. D reci
hemostasis doesn't work, and you rapidly reallze your ony opton is io
conirol obvious arterial bleeders, pack the damaged chesi wall, and
rapidly bdi lout. T-F"e are oftan lerhal in iLr ies.
Suture intercostal bleeders parallel to the nos
The injured lung
Despite obvious anatomical differences, the bleeding lung s strikngly
similar to the injured llver In both organs, you deal with peripheral iniurles
using a variety of hemostatic iechniques, while ceniral injuries {close to the
hilum) are very bad news. In both lung and llver, surgeons use hitar control
and non'anaiomical segmental reseciion but are wary of Jormal extensive
resection (lobecionry n the /iver, pneumonectomy in the lung). The
concept ol tractotomy, a most usef!l iechnique for ihrough-and{hrough
lung injuries, was originally borrowed from hepatic trauma.
Yo! can suture superficial pulmonary lacerations, but your most
effeciive weapon in dealing with the bleeding lung is sfapled nan-anatomic
resecllon. How s il done?
Define the precise
locat on of the injury and
use a l inear cutt ing
stapler to rapidiy open
the intef lobar f iss!re, i f
fused. Now, take a good
look at the injured lung
segment and plan your
line of reseclion. Your aim
is to remove ihe injured
trssue with the east
amount ot surrounding
heaithyparenchynra. Have
a I stap ers and 3:0 or 4:O
poprypropyrene sutures
rZ rne Chesi: rnslde onct Out @
Pulmonary tractotomy
rs a an elegani lung-
sparing solutton for
t h r o u g h - a n d ' i h r o u g h
penetrating injuries ihat
are too deep for a
slapled reseci ion. The
underlying principle is to
lay open the tract so you
can gei to the bleeders
inside it. In oiher words,
you connect ihe iract to
the lung surface by
dividing the br dge of
nssue between them.
readily avaibble before you start. Ask the anesthesiologist to momentarily
deflate the injured lung. Use eiiher a wide inear siapler (60 or gomm) or
several applications of a linear cuttng siapler to resect the injured
parerchyma. lf lhe stapled line of reseciion continues io ooze or leak atr.
underrun it wilh a cont nuous monofilarnent sut!re.
TOP KNIFE The Art a Croft ofTroumo Surqery
Inserl one arm of a l/near
cutiing stapler (we prefer io
use a vascular staple load)
into lhe missile tract and
apply the oiher arm to yo!r
chosen target sudace,
C ose ihe siapler and lire it,
layifg the m/ssile iract wide
open. Now, carefuly jnspect
I for beeding vesse]s and
suiure-ligate ihem selective y
using 4t0 polypropyene. Do
not close the traci,
lf yo! don i have a lineaf cuiting siapler, you can do the sanre tractotomy
between two iong aortic clamps appjied to the bridge of trssue overlying ihe
missiletract. After selectively co.trolling bleeders in the open iraci, underrun
each aoriic clamp wiih a 4:0 polypropylene surure before removing ii.
Pu monary lractoiomy works so well ihat you should consider using it
even in deep penetrating wounds that are not through-andthrough (i.e. no
exit wound). Inseri a fnger inio ihe mssi le tract and assess how mlch
uninjured lung parenchyma mlst be crossed to complete a thro!gh-and-
ihrough tracl. lf ihe dislance is short, use the stapler as a ,missile, to
complete the lraci, push ng ii through the tract uriil the iip emerges from
the other side of the lLrng. Part oi the tract will be iatrogenic, but a ?aci is
a tfaci, and therefore amenable to tractotomy. Lay it open and suture-ligate
individual bleeders.
Pulmonary hactotomy is a neat solution to a ditficult problem
BIG TROUBLE with the lung
Central lung injuries are deadly because they are difficult to controJ and
repair They are classrc examples of Blc TROUBLE (Chapter 2), where
orgafzing your altack and your team before jumping in can make an
enormous difference.
l2 The Chesl: nslde ond Out
When confronted
with massive bleeding
from an lnjury close to
the pulmonary hi lunr,
rapidly mobi l lze ihe
lung, gathering it in your
non-dominaft hand,
and pinch the bleeding
hllum beiween thumb
and foref inger The
simiadiy to ihe Pringle
maneuver rs oovous.
Now organize youf
anacK: rmprove exp
os!re, "mainslera ' ihe
endotracheal tube i.to the conlralatefal bronchus if possible, and get a full
sei of vasc!lar instfuments and an autotranstusion device.
At th s point, your oplions depend primarily on the mechanism of nlury.
With a simple stab wound, pinching the i f j l red hium may give yoLr jLtst
enough control and visibility to rapidly do a aieral repalr using 5:O
polypropylene. The situation bears an uncanny resemblance io the injured
portal ve n n the hepatoduodena ligament. In boih cases, you are dea ing
with a lacerated low-pressure (but h gh flow) sysiem wiih n a very narrow
anatornic space ihat affords you litlle room for maneuvering or comfortable
clamprng.
Control the pulmonary hilum between thumb and forefinger
A central glnshot injury is bad news. Dar.age is r.ore extensive, you
often must clamp ihe hilur., and may be forced to reseci a lobe (or even
the entire lung) io achieve hemostasis. A theoretically appeallng opton fof
hilar injuries is vascular control from within the pericardium becalse it is
based on the prlnciple of anaiom ca barf ers (C hapter 3) .
lf yo! open ihe pericardium anterior and pafallel io the phrenic nerue,
you are work ng if uninjured v rgin terrilory, much ltke working above the
inguinal lgamenl n a groin gunshot wound. However, this lakes t ime and
TOP KNIFE The A.t & Crcrii ol Troumo Surgery
requires thorough kfowledge oJ itrtrapericardiai a|atomy - nol a good
opiion for the gerieral ifauma surgeor facing a certral lung injury n a
rapidly exsanguinailng patient. In practice, a gunshot wound close to the
pulmonary hiufir means a rapid lobector.y or, in extreme circurnstances,
pneumonectomy,
A siapled pne!nrofectomy is a technically simple blt physlologicaly
devastatrng operatrve maneuverr so use it as an absoluie Last resod,
Exsanguinai ng traunra patients do not iolerate acute removal of the iufg.
Pneumonectomy slops the bleed ng but often eads to acuie right heart
failure, henrodyfamic collapse, and very high mortality.
lf, despite all efforts, you have no choice but 10 take out the lung, bring
a 90mm inear siapler w th a vascular staple load across the eni re hilum.
The iechnical princ ple is to move the siapler as d sial as poss ble io give
yourseLf room for a suture llne should siapling requife reinforcement.
Carefu ly close ihe stapler across the entire hilum, fire it, and remove the
ung. Take hold of boih edges of the stapled stump wiih Allis ciamps, and
oniy then release the staplerThere s always residual bleeding from the
stapled line of reseciion. Control ii wiih a running monof lameni slture.
Do a stapled pneumonectomy only as a last reso{
The thoracic esophagus
Approach an injury to the upper and midthoracc esophagus through a
rrght posierolateral thoracotomy in the 4ih intercostal space. The injured
lower thoracic esophagus is accessed ihrough a left posiero aleral
thoracoiomy in the 6-7th ntercostal space.
The bail out so ution for an esophagea perforation is proximal drainage
to conved the fiee perforaton inio a controlled fistula. The cardina sin is
creating a dead-efd esophageal pouch above ihe injury, an ufdrained
'pus sausage" that is a source ol ongoing sepsis and slowly kills the
paUent.
l2 The Chest: lnside and Oui
Drain the perforation by
insert ing a large-bore
suclion drain through ihe
perforaiion and up into the
proximal esophagus, and
secure it in place. lf you
can get an esophagea T,
iube, use it. lf possible,
approxrmate ihe edges of
the hole around the dfain-
A ways remember to drajn
the pleural space with a
separate drain or a tube
thoracosiomy. Use this
damage conirol opt ion
when you have to bail oui
approximated without iension,
24 hours from injury) and the
primary closure unsafe,
in a hurry, the injury s too large to be
or the operaiion is delayed (more than 12-
pleurai space is severely inflamed, making
An esophageal perfofaiion is a hole ln the gut. lf you decide to close it,
always begin by carefully debrjding and deflnlng the edges of the nrucosal
defect, just as you would do for any other part o{ the Gl tract. Do not
mobi|ze lhe esophagus out oI its bed because you will devascularze it,
jeopardizing your repair. Close the perforation in two layers (mucosa and
muscle), and drain the pleuralspace.
Coverihe repairwiih a vascularized pedicle of tissue. Depending on ihe
operaiive circumstances, ihis can be an iniefcostal muscle flap, a Thal
patch of gasiric fundus (Chapter 5), or a chunk of omenium. Perlcardial or
pleura flaps are not well-vascularrzed n ihe acute settinq, so don't use
them. Provide a roule for early enieral feeding
Drain an esophageal pe oration as a bail out solution
TOP XNIFE ]he Ad a Crofi of Troumo Surgery
The majol airways
The ciose anatomical proximlty of the major airways io the greal
vessels, esophagus, and lungs vidual ly guaraniees you wi l l rarely
encounter an isolated injury to the intrathoracic trachea or a major
bronch!s. [,4ajor airway injury typically iakes second seat to hemorrhage
because gushing blood takes prorily over leaklng air.
The damage conirol soluijon for an rntrathoracic tracheal irjury is io
negotiate the efdoaachealtube past the injury bypassing jt to prevent a
massive air leak. For a rnainstem bronchus injury, ihe bail olt soluiion is
mainsiemming ihe endotracheal iube into the contralateral bronchus
(Chapter l1). Air Jeaks from smaller arrways can be managed initially with
a chest tube, with delayed reseclion of the involved lobe.
lf, during thoracotomy for trauma, you ercounter a straighfiorward
lacefation of the trachea or a major bronchls, fix it with a sing e row of
interfupied absofbable sutures. Do not use a non-absorbable sutufe in the
airways; il leads to granu oma {ormaiion and tater stenosis. Fof all other
iniurjes thai require complex reconstrlctions, the smartest thing you can
do is resist the temptation io tackle them or your own, and get the help o{
an experienced thoracic surgeon,
)
Fix skaightforward major airway iniuries with absorbable suture
T H E K E Y P O I N T S
Suture inlercostal bleeders parallel io ihe ribs.
Pulmonary tfactotomy is a neat solltion to a difficult problem.
Conirol the pul. .onary hi lum beiween thumb and foref ingef.
Do a stapled pneumonectomy oniy as a last resort.
Drain an esophageal perforation as a bail out sotLrton.
Fix straightforward malor a rway injuries with absorbable suiure.
Chapter 13
' I horactc V ascu lar I ra uma
for the Ceneral Surgeon
The rcad to the heart is orrlY 2-3cm in a dircct lifie, but
it has taket surgery flearl! 2400 ye.rrs to haoel it'
- H.M. Sherman
Injlries to ihe heari and ihoraclc great vessels have an idtating
tendency to force lhemselves on you. ll you ate a g€neral sutgeon' the
major vascular structures of ihe chest are not your nat!ral habitat, and you
wou d much raiher have a cardiothoracic colleague deal with ihem With
bluni aodic injuries ihis is noi only Posslble but ls also a good ldea
because you are dealing with a contained hematoma There is time to
delineate ihe njury by angiography, conslder various options (including
endovasculaf repair), or transfer the Paiient to another facility Not so with
penevating itauma, where the patieni is actively bleeding and often ln
shock. You musi take a deep breath _ and plunge in A phone call to a
cardiac surgeon is noi a valid resusciiative maneuver for cardiac
This chapier deals with lhoraclc cardiovascular trauma from the
perspective of the general surgeon Most penetratlng injuries io the heart
and thoracic great vessels can be fixed using straightforward vascular
principles and techniques. lf you gain rapid access to the injury and keep
your wlts about yo!, yoLl have a good chance of saving the patent
Accessing the bleeding heart
The operative encounter with a stabbed heari is often one ol the "osi
reward ng experences a surgical resident can have li involves a rapld
simple procedure that revives a patlent who, uniil a {ew minutes ear ier,
TOP KNIfE lhe Arl & Croit of lroumo SLJrgery
was virtually dead. Don'i let ths gfatifying experience mislead you.
Cardiac inlufres can also be extremely vicious and leihal. They conre in iwo
flavors: simple and complex.
A simple cardac injury is a small accessible laceration, rnosl often a
stab wound. Oulcome is deierm ned by how quickly you crack ihe chesi
and release the tamponade. These patients don'i die ol exsanguination,
and cardrac repair is usually easy.
Complex injur ies are mutiple, inaccessrble, large, or involve the
coronary arteries. Re ease of tamponade is only the firsi step in an uphil
battle. Conrplex cardiac wounds are Blc TROUBLE (Chapter 2), carryifg
very high morlaliy rates even rn the most experenced hands.
How do you get io the wounded heart? lJ yo! have akeady begun with
a resuscilative lhoracotomy, open the pericard um longitudinally, anteror
to ihe phrenic nerve. Release the tamponade and deliver the heart nto ihe
operative fie d. Injuries io ihe righi side of the right ventricle or to the right
atrum cannoi be reached through a left anterolateral thoracotomy, so
extend your rncison across the sternum.
lf the patieni is not ,in exfremls, consider do ng a median sternotomy.
This incision takes a ittle more time, and your access to a postenor
cardrac wound from the front is more difficult. We prefer a left anterolateral
ihoracotomy for most cardiac wo!nds, especially gunshot inj!ries that
often involve damage to oiher ihoracic structures. We reserue median
siefnotomy for precordial stab wounds in relative y stable patients.
Do a left anterolatefal thoracotomy for cardiac gunshot wounds
4 A,MI @-4 ".z"zc1 
tW*V.-r"*
l
F 5f--',t ? +
to
l3 Thorocic VascuorTrauma for ihe GenerolSurgeon
Temporary bleeding control '
Once rnside the pericardium, rapidly evacuate blood and clots, locate
the injury, and select an appropriate lemporary hemostatrc technique. Youl
assistant's finger is an excellenl first choice, but there are other options.
During resuscjtative ihoracotomy in ihe shock room, temporarily
stapling the laceration wiih a skin stapler s a cooltrick since a stapler is
so much safer ihan a needle. Conirol a larger wound by inserting a Foley
catheter through the hole and inflating il. Use a Satinsky side-biiing clamp
to conlrola rohl atrial Laceration,
lf the damage is extensive or the
injury inaccessible, you may have to
resort to temporary inflow occlusion.
lf you clamp both the superior and
inferior venae cavae, ihe heart will
emptyand siop, giving you a couple
of minutes (not morel) to suture the
laceration in a dry field. ll you are not
a cardiac surgeon, the simplest way
io achieve inflow occlusion is by
co..press ng lne \lg!]._jl]Illl!!-r
manually againstthe heart in a lateral-
to-nredial direciion so the atrium
ToP KNTFE The Art & Croft of Traumo Surgery
cannot fill. Use inflow occlusiof only if you have no other chojce. lt is easy
to siop the heart, but much more difficult to get it going again. In a cold,
fibfillating heart, inflow occlusion will be a term nar evenr.
Inflow occlusion is your ultiftate weapon in cardiac trauma
Restarting the heart '
When the heart s not contracting effective y, begin open cardiac
compressions. lf operating through a median sternolomy, compress ihe
heart between bolh palms (wlihout thumbs). In a left anterolateral
thoracotomy your wofk space ts imited, so compress with one hand
against the sternum. Restartthe heart us ng a combination of open cardiac
massage, cross-clamping of the descending thoracic aorta, eplnephrine
(1mg) io achieve coarse ventricular fibrillation, and cardioversion using
iniernal paddles applied d rectly to the heart ai 1O-30 Joutes.
What should be your firsi priority if ihe bleeding heari is not coniractifg
effeclively? Should you fx the laceration first? Rapldly cosing a cardiac
laceration before it resumes danc ng rn front of you is certainly tempiing,
but it may take iinie, and your repaif nray fa I apart when you compress the
heart and iniect lnotropes. Epifephnne is the eremy of the myocardial
suture line because it induces forceJul coniraciions caus ng sutures to rip
throlgh the musc e. lf you fix the aceration and then restart the heart, you
may have to reinforce (or even redo) your suture line once ihe heart begins
beating again.
Resiariirg ihe heart after repair may not be easy. A severely acidotic
pal ient wl l benef i t f rom a bous of sodium bicarbonate pf ior to
deflbrillation. Even nrore mportant is external irigation with warm saline to
rewarm ihe head irnmediaiely before applyjng ihe paddles. Use lnotropes
only if nothing else works.
Epinephrine is the enemy of the myocardial suture line
l3 Thorocjc Vosculor Troumo for ihe cenerol Surgeon
Repairing simple cardiac wounds
C ose a simple laceration
with a 4r0 qg&absorbable
monofilam6nt suture. Sew n9
the contracUng myocardium
is more di f f icul t than
optimisiic lluslraiions iike this
lead you to believe. Noi only
are you workng on a movrng
targei, you aso are dealing
with a muscle that tears quite
eas ly,
Some surgeons use Teflon pledgets to reinJorce the sulure ine. We
repa r a lacerated veniricleaviih interrupted simple sutures. Your bites inio
the heart muscle should be deep but not full-thickness. The diffcult part is
not placing the suiures, but tying them. Unless you take special care not
to tighien the knols too much, you will end !p with a torf myocardium and
a bigger hole ro fix.
ln an elderly patient or an edemaious or friable myocardium, use
horizontal mattress sutures wiih pledgets. Partial inflow occlusron by
manually compressing the right ak um lowers pressures in the v€ntricles,
a useful adjunct when sewing a compfomised myocardium.
Since pressure in ihe righi atrium ls low, you often can control an atrial
laceration temporar ly with a partially occluding Satinsky-type clamp and
then fix it with a running suture, as you wouLd a arge vein. Grazing non-
penetraiing rnyocafdialwounds often b eed persistently and require suture
repaif just ike a lull-ihickness aceraiion.
Tying sutures is the challenge when sewing head wounds
E ,o, a",rr rnu on & croJr oi Troumo suraerv
Complex catdiac wounds
. 
When.you can,t fix the injufed heart wiih a few simple sijtches, you are
f T-n-". ?.,^1 "1n".,. :"d 
yoJr oarieni ras a nigh ,ihetihood or 1or na(.ngrr , une $uch eramplF is a poster io. card,ac wound. to get,o a postertoi
hole, you musi Jift ihe heart out of its bed, but the heart often protests by
devetoorrg ventncLla. arrhylhmia or arresring. In fact, trl ng lre reert up ,s
anorher way oi achievirg in|ow occtusion, Be aware of th,s wnen yoJ
manrpulate the heart, and lift ii gentiy and intermillently when addressing aposlerlor hote,
The technical solution
for a /aceraiion ciose to a
coronary artefy is a deep
horizontal mattress suture
that dives beneath the
aftery. Take special cafe
when tying this suiure
because S-T segment
changes or new O waves
on the ECG monitor may
force you to remove the
str tch and fedo i t . An
Inlury to the coronary
artery itself is iypicaly
distal sinc_" paiients with
transection of a proximal
coronary vessel are usually
dead on arr ival . Your
real is i tc opt ion for a
cardiac laceration with a iransected distal coronary artery is to ligate the
vessel and repair the hole, accepting ihe inevitabte ischemi; of the
correspondrng myocardial seoment.
ir r+ *,:*! . '*-",rJ 
',,, 
^{\-i1 " L.^4
Cardiac tamponade caused by lnjury to the intrapericardial oreat
vesse's is usJal lyreha,. On rhe ra.e occdsiol l ratyor, pnco.:rre, i . i r I hve
patient, success hinges on your ability to fapidly identify the inlury,
l3 Thorocic voscu ar Troumo for lhe GenerolSurgeon
temporadly conlrol il wiih your Jinger or a Saiinsky clamp' and fix ii with
simple latefal repair 'much easier said than done
In traurna atlases and iexlbooks you ofien see descriptions of heroic
repair techniques lor an injured coronary artery, patch repair of a large
myocardial defeci, or complex reconstructions ol the inirapericardial great
vesseLs. Althese may be possible in special c ircumstances when a
cardiolhoracic surgeon and a pump team happen io be readily available
However. for ihe routine trauma paiient arriving in the middle of the night
with a penetrating cardiac lnjury and operaied on by ihe traurna surgeon
on calL, lhey are science ficlion.
Use quick and simple solutions for complex cardiac injuries
The tholacic outlet
How to exvlore a meiliasfi al her atoma
Median sternotomy provdes
excellent access lo the superior
mediastinum. A mediastinal
hematoma looks Like a large
chunk of red jelly sitting above
ihe pericardium, oozing blood
and obscuring the anaiomy.
This red jelly usually signifies a
major vascular injurY in ihe
ihoracic oulei that You mlst
find and fix.
Exploring ihe suPeior media_
slinum is remarkably simllar to
expLoring ihe neck, as described
in the nert chapter. Both are essentially a lrip ihrough a minefield under
sniper flre. You must follow a trail of safely from one key anaiomlcaL
landmark to ihe next to guaraniee a safe dissection and siay oui oftrouble
TOP KNIfE The Ari & Croft of Troumo Surgery
Once ins de ihe chest, identify
the upper border of ihe
pericard um. lf the ihymus is in
your way, divide it between
clamps and ligaie lt. You are
looking for the ielt innominate
vein. lt is the gatekeeper of the
mediastinum, just as the facial
vein is n the neck. Divding and
ligaiing the lefi ifnornnate vein
opens !p the supe ormediasiinlm
and gives you access 10 ihe
supeior aspeci of the aortic arch
and rts branches.
Disseciion n a mediastinal
hematoma is never easy. lf
you fee ost, a useful lrick
is to open the pericardium
to or ient youfself . The
pedcard um is an anaiomical
barr ier that blocks lhe
extension of lhe mediastinal
hematoma, jusi l ike ihe
inguinal igament blocks the
extension of a groin hem-
atoma (Chapier 3). By
opening the per cardium,
you can follow ihe aortc
arch upward into ihe
hemaloma to identify ihe
vessels oJ ihe ihorac c
outlet.
I 3 Thoroclc voscuor Trou mo for ihe Genero Surgeon
has ihe same consequences as il does
iatrogenic iniury
After ideniiiying and
dividing the left lnnominale
vein, your next stop on the
mediastinal trail of safeiy is
the bifurcation of ihe
innominale ariery, the media_
st inal equivaleni ot the
carot id bi furcat ion In the
neck. Your kay landmark is
the right vagus nerve as lt
crosses in front of the
proximal r ight subclav an
artery. Fallure io identi{Ylhe
vagus in ihe mediast inum
ln the neck - an inviiaiion for
Follow a trail ot safety in exploring an upper mediastinal hematoma
Youf nexi priority is proximal and distal control of the bleeding vessel
The vessels of ihe superiot mediastinum are niceLy arranged in two layers:
s!perficialveins and deep arteries Again' the simllarities to the neck are
strlklng. Control a venous injury with a side-biting clamp, and fix ihe hole
lf a simple lateral repair will noi do _ ligaie the veln without a second
thoughi.
When disseciing the proximal left carotid artery, you musi ideniify and
preserve lhe left vagus nerve as it descends between the caroiid and Left
subclavian artedes to cross in front of lhe aortic arch and give o{f the left
recurrent laryngeal nerve Proximal controJ of the lefi subclavian artery Ls
discussed laier in thrs chapter
Never just plunge inio a mediastinal hemaioma from blunt trauma The
most common blunt arterial injury in the upper mediastinum rs an
lnnominaie artery injury that presents as a coniained her'atoma (widened
superior mediastlnum) in a hemodynamcally stable patient Bllndly
entering lhe hemaloma is the worst possible error you can make lhe
inlurv js avulsion of lhe lake_off of the innominate artery Jrom lhe aortic
aich. In other words, you are dealing with a sde_hole in the aorta lt
TOP KNIFE The Art & Craft of Troumq Surgery
doesn'l take much surgical imagination io realize what wil/ hapoen if vou
oelve nto -hrs rFnatonc u'rprepa.eo. lne correcl approac- is or;Jlv
ouilined in the next section of this chapter
How about distal
control of thoracic outlet
injuries? As a general rule,
the exposure provided by
a median sternotomy is
olten not suffic ent to a ow
dista conifolof the carotid
and subclavian vessels. A
medran sternoior.y is,
however, an eminenily
extensle incision, so yor,l
can easily cafiy it Into the
neck or along the clavicle.
lf you are going into the
reck, drvide the strap
muscres oown |ow, fear
the r inseriion inio the
sternum, to expose the
carotid sheath.
Never plunge blindly into the mediastinum in blunt trauma
Definitive repair and damage control options
In the upper mediastinum you almosi never dea/ wiih an isolated
penetrating injury to a single vesse. There are always associated inlures,
and clamping the rnnominate or caroiid artery carrles a subsianial risk o{
stroke. So don't fiddle w th ihoracic outlei iniures; use the simplest afd
quickest solution that will give an accepiable result. In most cases, this
means a synthetic rnterposjtion grafi. We prefer knitted Dacron ratherthaf
ePTFE because il is a softer graft with less needle-hole bteeding. The
1 3 i ' o o . ' , o , u o ' I o u - o o I ' G e _ _ ' o l 5 
' g e o n
normal arteries of the thoracic oullet afe extremely friable, and sewrng
ihem often feels ike sewing wet lissue paper
There are ony linriied damage control options in the thoracic ouilei
Ligaiion of the injured artery is certainly an option if you accepi ihe risk of
slroke. A temporary intraluminaL shuni is iheoreiically aPpealing and has
been used twice by one of oLlr colleagues but with no ong_lerm survivors
The only speclal vascular technique in the thofacic outlel is the 
'bypass
and exclusion repair of blunl innominale ariery lnlury ll you aren t a
cardiothoraclc surgeon, you are unlikely to find yourself operating on this
injury, since the paiients are hemodynamlcally siable with a coniarned
hemaioma. You should, however, be familiar wiih the techn cal principle
The bypass and exclusion repair begins by exposing the ascendlng
aorta inside the pericardiunr and then obtaln ng disla! contro on ihe distal
innominate, right subclavian and right carotid arteries The s!rgeon
deliberalely avoids enteing the hemaioma around the ptoxlrnal innomlnaie
artery. A pariia ly occlud ng Saiinsky clamp placed on ihe ascending aoria
allows ihe surgeor to sew a 12nrm knitted Dacron graft end{o side io this
sde-clamped aortc segrient The innominate adety ls then dlvid€d just
proximal to its bifurcation, and the distal anastomosis (io ihe disia
innominate) is completed Onlyihen isasecond part ial ly occ uding camp
placed on the aorta around lhe take_off of the lnnominate artery The
hemaioma is entered, and the side hole in ihe excluded segmeni of aorlic
arch is closed with pledgeied sutures
[Jse Dscron fof thoracic outlet arterial reconstructions
The azygos vein
In penetrating chest traunra, azygos vern
wth lnjures to the adjacent centralalrways,
vessels. The chalenge with an azygos vein
through a median sternolomy is extremely
injury is seen in conlunctron
esophagus, or thoracLc out et
injury ls gelting io lt. Access
ditficult, and it may even be
TOP KNIFE The Ari & Croft ol Troumo Surgery
difficult io reach lhrough a righi anterolateral thoracotomy, requiring an
extension across the sternum. The irjury is tolgh 10 identify because what
you Lrsualy see s just a hole in ihe right posterior mediastinum hosing
venous blood. Onc6 identified, clamp and suiure-ligaie the injufed veln,
and meiiculously search for associated jnjufes io the adjacefi bronchus
or esophagus,
The subclavian vessels
Before you embark on an adventure around ihe sLlbcavian vessels,
palse to assess how necessary it really is. Are you operatjng for bleeding
or ischemia? l f your circumslances are unJavorabie ( i .e. austere
environment, lack of experience, other grave injuries), you nray well be
ab e to posipone the operation. If bleeding is from a missiie tract, inseri a
Foley nto it and inflaie lhe balloon (Chapter 2). lf this stops the bleeding,
an lmnrediate opefatlon may not be necessary. lf ihe arm is ischenric, a
simple forearm fascioiomy can buy you valuable time. Endovascular stents
or stent-grafts are effective ali€rnatives to surgical repair of subclavan
injuri6s in non-bleeding patients.
lf you decide to proceed with an operation, proper positioning and
draping are crucial. Place a shouldef roll vertically along the thoracic sprne
to drop the shoulders back. Suppod the head and roiate it to the
contralatera side to extend ihe neck. Prep and drape the patrenl's chesi
with the upper exiremiiy prepped free so it can initlally be fully adducied at
the patent's side and later abducted as necessary. You can get to the
subclavian vessels through either a supraclavicular incision or ihe bed of
the clavicle. Your choce of incision depends on the opefai ive
circumstances and your experience.
lfyou are not sure whefe the njury is located along the subclav an artery
or if you don't have experience with subclavian exposure, the safest way
to obtain proxjmal controlis throLgh the chesl. Use a high (3rd irierspace)
eft anterolaiefal th oracoiomy incision for injury to the left subclavian artery,
or nredian sternoiomy if the injury is on the righi.
I3 Thorocic vascu orrro!mo for the Genero "'ntt" 
E
When exploring a non-bleeding
subcJavian injury with mrnimalor no
hematoma around the clavicle, we
prcfer a supraclavicular incision
lvlake your incision a lingefbrcath
above and parallel to the clavicle,
extending from the sternal notch
lalerally to the distal third oi ihe
bone, a distance of approximaiely
8-1ocm. Divide the Platysma and
place a self-retaining tetractor in
the wound, You must now go
through two layers of muscle.
Behind the divided slernocleidomastoid, idenlify ihe scalene fat pad and
caretully mobilize it from lateralio medjalln search ofthe phrenic nerve On
lhe left side, you should be able to identit ihe thoracic duct as ii enters the
iunclion of the left subclavian and iniernal jugular veins lf iniured' suture'
ligate it with a 6:0 polypropylene suture; il not' eave I abne
Th€ first layer conssis
of the claviculaf head of
the sternocleidomastord
and the omohyoid laierally.
Cut both muscles as close
to the clavicle as Possible,
then reposition Your
retractor in a deeper Plane
to op6n the wound. lf You
see the internal juguLar
vein, deiine its latetal
border and reiract it
mediallyoul o{ harm sway
Now you can access and
isolaie the subclavian veln,
bul the artery is hiding one
layer deeper down, behind
ihe anierior scalene
TOP KNIfE The Ari & Croft of Troumo Surgery
f , - \ 4 - ' Y 
L " J ' A
The key analomical
iandmark n exposing the
subclavian artery is the
phrenic nerve behind lhe fat
pad. During a subclavian
exposure, i t is the ort
slructure you must preserve
at any cost, even f the
anatomy is hostile. lt
crosses the anterior scalene
muscle from up and lateral
1o down and medial. lsolate
the nerve on a vessel loop
and gently reiract it out of
your way, Now cui the anterior scalene mlscle as low down as you can,
We dlvide the muscle piecemealwiih scrssors and noi diathermy because
it does not bleed and is close to the brachia plexus.
Only a lhin periarter a
lascia rernains between
you and the subclavan
adery Incise it to identrfy
the periadveniitial plane
of safeiy and encirce the
artery. The thyrocerucal
trunk s com ng straight at
you and ls typically in your
way. Dividing and ligating
t helps you nrobilize ihe
subclavian artery. Clearly
identify the vertebral and
Intemal mammary arteaes
comirg offthe firsi part of
ihe vessel to prevent
accidentalrnjury.
The phrenic nerve is your key to the g.tbclavian a*ery
! 3 - h o r o - ' . v o . ! o , ' r o 1 o o 
_ e C a n ' o 5 r o e o '
As always, things become considerably livelier when lhe subclavian
adery is bleeding An expanding hemaioma fiLls the clavicular fossa'
making it difiicult to even palpate the clavicle When operatlng under such
adverse circumsiances, we prefer to go throlgh the bed of ihe clavlce
because i s a quiuker a1d simplef toLle
'/h.t",'\ 4rd'1 +^ PL- 'lA
Make your incision dLrectly on the clavlcle io expose the medial hvo_
thirds ofthe bone. Score a line on the anterior surlace ofihe bone wiih ihe
dialhermy. Now use a periosteal elevator lo peeL ihe periosteum otf the
clavicle in a circum{erential fashion Divide lhe clavicle as far laterally as
you can wiih bone cuiters or a saw, then grasp ihe medial ffagment with
a towel cLip, and yank ii oul of iis bed Using ihe diathermy, take the head
of ihe clavicle off the siernum. Cutting the subcavius muscle immediately
deep to the clavic e bf ngs you face-toJace wiih the pfe_scalene lat pad
and the phrenic nerve, and you know your way io ihe artery from ihere
Distal controL ol the subclavian artery may require clamping the proximal
axillary artery. lf the clavicle is intact, clamp ihe axillafy artery through a
sgpil3lCjlll3gbllg.Ulqr incision Howevet it you temoved ihe clavicle, you
hive an extensile inclsion ihat can be cary'€d laterally toward ihe
aeltop"ctoil $ooi66 ""pise 
the axillarv artifi=_
The damage conttoloptons for an injLlred subcavan ariery afe llgation
or lemporary shunt ing. Boih wofk Ligauon is usual ly wel l toeraied i f the
iniury has not destroyed the major co!lateral pathways around the shoulder
Adding a pre-emptive forearm fasciotomy is a prudeni move'
lf you know your way around ihe niured subclavian ariery and don'i
have 10 bail out, repaif it Unless dealing with a aceraiion that can be fixed
wilh simple laietal repaif, we again advlse you go directy lor an
intemosition graft. Mobilizing the sott and friable subclavian ariety to gain
enough length for an end-to-end repalr a most never works We isolaie ihe
injured segmeni and clamp ii, define lhe lnjury, do a proximal and distal
F;gady thrombectomy, and lnsert an 8mm Dacron interposition graft We
do noi replace the clavicle after completing the vasculaf reconstructlonr
bul cover the tepair with healthy muscle and soft lissue
Go through the bed of the clavicle if the patient is bleeding
TOP KNIFE The Arl & Croft of Troumo Surgery
The descending tholacic ao*a
The patient wlth blunt lnjury to the descending thoracic aorta is typica ty
hemodynamlcally stable and has a coniained mediasiinal hemator.a. Don,t
iorget that if the paiieri s unsiable, ihe source of hemoffhage is alnrosi
nvariably in another analomical compartment, iypically below ihe
oraprragrn,
Again, if you are not a cardiothoracic surgeon, you are not likely io find
yourself in the left chest, face.toJace wiih a bluni aortc injury. Howevef,
be famlliar with ihe g eneral tech nrcal principles of the repair. Endovascular
t.eatment offefs an effective alternaiive to operaiive repair ofthese injuries.
Although stil under evaluation, this nrodalty may become the preferred
approach within the next few years.
The classic blunt aodic injury, locaied immediately distal io the take-off
of ihe left subclavian artery, is repaired through a left posierolaieral
ihoracoiomy in the 4th ntercostal space wih single lung ventilation. The
major palhophysiological chailenge is central hypertensron caused by
proxmal aort ic c lamping. Pharmacological agents, a passive shunt, or
pump-assisled atriofemoral bypass, typica ly using a centrifugal pump and
no hepann, are your optrons.
The technical difficulty in ihis operation siems from the close proximity
of ihe aortic tear to the origin of ihe subclavian adery. The pleura overying
the proxima eft subclavian artery s opened, and ihe adery s encircied by
blunt disseci ion. Using a combinaton of sharp and bl !nt disseci ion, ihe
surgeo. then encircles the aorta between the left subcavian and efi
caroiid arteries, creatingjusl enough space to accommodate a clar.p. The
key maneuver is developing a plane between the lndersurface of the
aortic arch and ihe pulmonary artery. Dista control is obiained by
encircling ihe drstalthoracic aorta above the diaphfagm.
After clamping, the hematoma s entered and a careful longiiud nal
aortotomy allows the surgeon io assess the extent ofthe njury and decide
beiween primary repair (feasibl€ in roughly 15% of cases) and Dacron
graft inlerposition.
I
I
13 Thorocic vosculorTroumo tor ri'e ceneror'surseon $
) Do a left anterolateral thoracotomy for cardiac gunshol wounds
) Inflow occlusion is your ultimato weapon in cardiac trauma
> Epinephrine is the enemy of the myocardial suture line
) Tying sutures is the challengowhen sewing heart.wounds'
> Use quick and qimple golulions for complex cardiac injuri€s .
> Follow a trailof saf€ty in exploring an uPper m€diastinal hematoml'
) Nover plunge blindiy into the msdiastinum in blunt trauma 
- '
) . Usq D4gr-arriQr tharacic outlet arterial teconstrucJions i
) The phrenic nerve is your k€y to th€ subclavian artery
) Go through the bBd of the claviclo if th; patient is bie€diirg'
IOP KNIfE The Ari & Croft of Troumo Surgery
Chapter 14
The Neck:SaJari in Tiger CountrY
Go to the heart of dange4 fot therc you will find safetq,
- Old Chinese proverb
The wounded neck is the anatomical 'tiger country," a group of viial
midline struciures tighty packed together, carrying a large neurovascular
bundle on each side. This delcate anatomy is jusl sitiing inside a lafge
hematoma waiting for you to make a wrong move Even surgeons with
eleciive experience in the neck w ll be chaLlenged by a rapid y expanding
cervical hematoma ihat obscures key landmafks and dlstorts the anatomy.
To avoid geiting lost in ihe injured neck, use the trail of safety, a well
defined sequence of steps thai carefully guides you from one key
anaiomical landmark io the nexl without getting losl of causing iatrogenic
damage.
TRAIL OF SAFEW
Jugulafvein
W1W'7@=
Follow a trail of safety in neck exploration
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TOP KNIfE The Ad & Croit oi Troumo Surgery
Before you begin
Always position the paiient yourself. lmproper posilioning can turn a
straightforward neck exploration inio the safar from hell. Support lhe
shou ders on a shollder roll, and use a head support to exlend and fully
rotaie the head to the other side. The superior med asiinum is an extension
ol the neck (Chapier 13), so your operatlve field extends from the masto d
process io the upper abdomen and includes both neck and chest. Never
begin a neck explofaiion without a fulL set of vascular nstrlments,and
remember io prepare a site for posslble vein harvesting from the leg
Making the incision
The ut ty incision for neck exploratLon
runs aong the anterior border of the
sternoc eidomastoid muscle (SCM). You
can ei(elrd lt from the masioid process
io ihe sternal notch, but a morc limited
inclsion is usually good enough. lf you
must go a ihe way io the sternal notch,
you may be dea ng with a thoraclc ouilet
lnjury where proximal conirol must be
gained n the chest. As you approach ihe
angle of the mandibe, curve your
incision posieriorly to avoid ihe marg na
nrandibular branch of the facal neNe.
The f i rst layer you encounter
beneaih the skin is ihe platysma. As
it is div ided, the edges of the nclson
open, and you are ooking for the
anierior border of the SC[,4, your first
landmark on the trail of safety. This
may not be easy in an injured neck
with an expandlng hematoma.
I
(-,
(
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l4lhe Neck: Sofari in Tiger CounTry
The most common pilfall is nraklng your incision ioo posterior lf, upon
divldlng the plaiysma, you bump inio longitudinal muscle fibers' move your
disseciion anteriorly Gaining ihe anterlor border of the SC['4 is more
irnponarl t ral ga n ng tre midhle 4 alaparolomy incisiol Asyou€ppy
o"fiU"rut" uu"oo. *nif" voLr ass'sIant apprres coLrnten'actro'l the incision
almost opens ilself.
Gain the anterior border of the sternocleidomastoid
Develop youl work space
Free the anterior border oJ ihe SCIM by pulling it toward yo! and Inserl
a self-reiaining retractor beLow ihe muscle to keep the wound open Th s
ls lhe firsi step in develop ng your work space
You are now dissecting ir
ihe nriddle cervical fascia, the
Layer of areolar tissue beneath
the retfacted SCM. Yout aim is
io ideniify the inietnal iugular
vein (lJ), your next landmatk on
the trail of safeiy.
The lJ is the most commonlY
injured vascular structure in
ihe neck. Temporari lY control
bleeding from this vessel wiih
your finger or a small side-brting
vascular clamP, and rePair it
Lrsing a 5:0 PolYPfopylene
suture. Dont hesitaie to lgate
ihe vein l f repair is not
slraightfoMard. lf the U is not
injured, siay focused on fis
anterior border, which leads to
the nexl landmark on the trall of
safety - ihe faclal ve n
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TOP KNIFE The Art & Crofi of Troumo Surgery
The facial vein is the
gatekeeper of the neck, the
key landmark you must
identify, clamp, and ligate to
open the way 10 the carotid
bi furcat ion. Ligat ing and
dividing it also allows you to
cont inue developing your
work space by repositioning
the self-retaining retractor in
a deeper layer so it pushes
the U out of your way. Yoll
are now drreclly on top of ihe
carotid artery. In most
paients the facial vein is also
a convenient marker for the
level ofthe carotid bifurcation.
In the presence of a large hematoma, taking the necessary time to
dissect out the facial vein s a smart move, even if you are in a hurry. Keep
in mind thai some palienis have 2-3 small veins instead of one large facial
vein, and all must be identified and divided along the anterior bofder of the
U. A classic pitfall is mistaking the lJ {or the facia vein and lgat ng it, only
to make the drsseciion more difficult. You have negolialed Ihe trailof safety
through the injlred neck. li's t me to begin the nexi part of yolr operatoni I
idenlifying and fixing the lnluries. 
i
The facial vein is the gatekeeper of the neck
The injured carotid
Gaifiirrg cotlttol
The cardinal prlnciple of obtaining proximal contfol before enieing a
hemaloma applies to carotid ariery injury and means isolating the vessel in
virgin territory pfoximal to the hematoma. You may occasjonally have to
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l4 The Neck:Sofor i in Tlger Country
ertend your incision to the
sternal notch or even rnto a
nredian sternotomy to
obtain safe proximal
control. Once inside the
cafotid sheath, find, identiiy,
and protect the vagus
nerve. Encircle the common
carotid ariery with a
Rurnmel tourntquei and
proceed with dissection
toward the area of injury
How about dislal
control? This is otten
problemaiic because a
cervical hematoma typically
exiends up io the angle of
the mandible (Chapier 3). Therefore, gaining dlstal control outside the
hemaloma may not be possible lnstead, prepare to gain distal conttol
from wlthln the hematoma. lf you are ready for ii, you can control back
bleeding from the iniernaland exiernal caroiid arteries with minimal loss of
As wiih any other named artery in the body the safe plane along the
carotid that protects you from mischief is the periadventitial plane (Chapter
3). As you reach the injury, you encounter back bleeding from lhe internal
and exiernal carotid arterles. First, use your fingef for temporary conirol
Then, eiiher clamp the distal artery or insert an intralunrinal Fogarty
catheter connecied to a 3-way stopcock into the outflow tfact. Remember
that the hypoglossal nerve cfosses over ihe proximal internal caroiid, and
the vagus nerve lies just behind it You have come to the heari ol tiger
country, so stay in ihe sa{e periadventilial plale and bluntly push asrde
(rather than cut) any unideniified struciures Definitive control of ihe
carotid bifurcation means occluding all thtee vessels: the comrnon'
internal, and exlernal carotid arteries
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TOP KNIFE Ihe Art & Crofi of Troumo Surgery
Once you have control of the lnlured carotid, lalk to the anesthesiology
team lo assure the patient has a good blood pressure (a mean of ai least
100mmHg) while the carotid is clamped. This is even more critical if
backflow from the internal carotid is not very brisk.
Stay in the periadventitial plane of the carotid
C arotid f ep &its siflxplified
The carotid artery olayoung healihy aduli s surprisingly soft and pliable
and doesn'l toleraie abuse. Unless you are very gentle, you will end up
wiih a lorn artery or a repair ihat looks like a dog's breakfast and has to
There are many cool trcks for repairing the carotid artery, incuding
such soohisticated maneuvers as transDosiiion of the mobilized external
carotid to connect it to the disial internal carotid. We advise you lo keep ii
very simp e and forgetthe coo siuff- oryour pat ient wi lpay the pr ice with
a stroke. use ihe simplest and fastest means to revascularlze the bra n.
Are ihere damage conirol options for a carotid injury? Definilelyl We
have no personal experence wilh temporary shunts in the carotid, bui rt
makes perfeci sense. lf the patieni s about to breach lhe physiological
envelope or there are olher mofe life-threatening injuries, ligation is a valid
oplion. When considering igaiion, remember lhe d tierence between ihe
common and inlefnal carotid arteries. Ligating ihe former is often well
tolerated because the interna carotid remains perfused by backflow trom
the exierna cafoiid. Ligaiing lhe internal carotid, especially in a
hypotens ve palient, caffies a significant risk of stroke. You may decde lo
lake that risk to save the patieni s life. Ligation s your only realistic option
for inaccessible rnternal carotid injuries in Zone lll. Some surgeons ligate
ihe internal carotld ariery if lhe patent has a profound neuroLogical delicit
(coma), while oihers reconslruct il regafdless of the patient's neurological
sialus. The prognosis rs going to be very poor rn efher case.
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l4 The Neck:5ofor l in Tger CounirY
What are the definitive repair opiions? On Tare occaslonsi a clean
laceration (usuallya stab wound) may be amenabl€ to simple lateral repair
or end{o'end anastomosis. In most cases we use a synthetic graft or
Datch 1o r€constructthe carotid. We rarely use vein because it takes more
iime to harvesi and prepare, and there is no good evldence thatthis makes
the slighiest diff erence.
Begin by exploring the injury. Open the arlery longitudinalLy in ihe lniured
areato define thefullexlent ofihe damage Caretully debride the coniused
or iniured segment to oblain heallhy aderial wall wiih a normal intlnra on all
sldes of the arterial defect. As you define the injury plan ahead
Precisely define the carotid iniury
Your nexl step is thrombectomy to clear ihe inflow and outflow tracts
Carefully pass a No. 3 Fogarty balloon catheter proximally and distally.
Don't push the caiheter dlstally more than 2-3cm pasi the bi{urcation -
diving ii through ihe carotid siphon will have spectacular results Flush the
proximal and distal ends of the injured artery wilh heparlnized saline and
begin the repair. lf inseriing an interposiiion graft, do the disial
anaslomosis firsi, especially if you are hooking up io the iniernal carolid
above the bifurcation. lt is difficultio work on the posterior wallofihe distal
anastomosis when the proximal anastomosis is akeady sewn in
Whal should you do if there is no backflow from the dislal Internal
carotid ariery? This is a conitoversial poini. We prefer to hgate the artery,
lor fear of convertng an ischemic stroke into a hemorthagic one Some
surgeons feconstruct the artery regardless of backflow
lf you have experience with elective carotid surgery and know how to
smooihly insert a shunl and work afound it - consider do ng just lhal A
shunt is a smart move, especially if backflow from lhe iniernal carotid is
weak or reconstruction is going io take iime Thtead your shunt through
the lumen ofthe lnterposition graft before insedion, and do the€niire distal
and mosi of the proxlmal anastomosis with the shunt in place
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TOP KNIFE The Art & Croft of Troumo Surgery
A carotid injury in Zone lll is uncommon and should ideally be idenilfed
preoperaiive y when youf control options are eiiher a Foley balLoon
caiheter nserted into the missile tract or angiographic occlusion.
But what if yo! encoLnier a high iniernal carotid injury duflng an urgent
exploration? You cannot reach the dlstal internal carotid without optimizing
your exposure. In the presence of relentess back bleeding, yo! have no
iime for e aborate maneuvers such as subluxafion of the iaw Your best bet
is a rnuch simoler alternative - a muscular and deiermined assistant armed
with a suitable retractor Extend your incision to the mastoid process,
insert a retractor inio the upper corner of the wolnd, and have your
assistant p ul rea ly hard, giving you a few cr iical mi limeiers. lf this is not
enough, divide the poster ior bely of the dgast ic musce to gan more
When all you can see s the
bleeding orifice of the iiternal
caroiid, lgation ol the ariery is
yo!r only fealistic opiion. The
injury is simply too high for
reconslructon. l f there isn' i
even enough length to ligate
or appLy a melal c ip, cons der
inserting a Fogarty catheter
inio the beeding or i f ice and
infaiing it. Apply iwo metal
c ips across the catheter very
cose to lhe bal loon, and cul
the catheter proximally, leaving
the permanently inf laied
balloon insde the artery. lt
may not be the most elegani
sol l t ion ln ihe book - bui i i
Ligating the carotid is not I crime
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l4 The Neck:Sofor i in Tlger Colniry
Exsanguination f rom bone
Have you ever seen exsanguinat ing
hemorrhage Jrom a hole in a bone? This is how a
vedebral artery iniury often presents in the open
neck. In the era of liberal angiography, ihis should
be a rare si iuai ion because the prefelred
rranagerent ol velebral arterv i ' r lu. |es is
angjographic, not opetat ive. Occasiona ly,
however, you will discover ihat the cafotid sheath
is Inlac- wl i le audible ane' idlbleedrng 15 spuning
from a hole in ihe pafaverlebral muscles lateral
and posterior to il. Feel for the bodies of the
cerylcaL veriebrae to orieni youtself, and you will realize that bleeding ls
coming from the area of the iransverse processes lf you swipe the
paravedebral muscles laierally with a Petiosteal elevaior, you are met wth
ihe !nforgetiable slght of bdsk hemorthage from a hole in a bone' ihe bone
being the transverse ptocess of ihe iniured ceruical vertebra
The several ingenious technlques described for this exotic injury are a
sure sign lhal many crealive surgeons have found ii a bafiling ptoblem
Unfooling ihe injured artery in iis bony cana is a demanding technicalfeat
even under the besi eleclive circumstances We certainly don'tconsder it
a feasible optlon in a bleeding patent,
and neither should you. Proximal
conirol of the injured artery ai ihe base
of ihe neck will not conirol backflow
from the brain.
Here, aga n, the simp est solulion
is ihe besi. Pushing a piece of bone
wax inio the bleeding hole usually
works like magicl lf your facility has
angiogfaphic capabilities, immediate
postoperaiive angiogram wiih embol_
ization of the injured vertebral ariery is
anothef option.
Use bone wax to plug a hosing vertebral artery
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TOP KNIFE The Art & Crofi of Troumo
The esophagus
SLrrgery
There are two routes io
the cervical esophagus,
going ei ther medial or
lateral to the carotid
sheath. The nredial route
is a natural continuation of
carotid exploratron and
probably the one which
you are most far.iliar wiih.
Before exploring the
esophagus, ask ihe
anesthesiologist to insert
a large-bore nasogasiric
tube to help you identify the esophagls by palpating the tube in a hostile
operative field. The esophagus is located slighily to the left of the midline,
making it easier to explore from the left side of the neck.
Retract ihe conient of the
carotid sheath laterally and enter
the plane between it and the
trachea. You wi l l f ind the
esophagus behind lhe t fachea
and anieror to ihe spine. Ful l
exposure of the esophagus
requires you identify and divide
three structures ihai cross over
the esophagus: the omohyoid
muscle, middle thyroid vein, and
infer or thyroid ariery. The
recurrent laryngeal nerue is rarely
identified in the jnjured hosiile
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l4 The Neck:Sofor l in Tlger Cowiry
The other approach to the esophagus, going lalerallo ihe carolid adery,
is a "back door" approach, Llseful when a large hemaioma in the caroiid
sheath obscufes ihe anatomy Retract the caroiid sheath struciufes
medially insiead of laterally, and enier ihe plane between the carotrd
sheath and the cervical spine to find the esophagus Your work space is
limited, but you are Iess likely io cause iatrogenic damage.
Approach the iniured esophagus th.ough a fiont or back door
Esophageal lniuties are noi easy to idenlify because the esophagus
doesn'i have serosa. lf you can'l be sure there is an injury, goide the
anesthesiologist to pull ihe nasogastric tube to the level of your
expLorai lon, f lood ihe operat lve f eLd with saine' and ask the
anesthesiolog st to inllate ihe nasogasiric lube with air' Waich for
emerging air bubbles.
The most worrisome aspect of an esophagea exPotaiion is noi what
you can see and feel, bui what you cat'l Is there an injury to the other side
ol ihe esophagus? To ihe posierior wal? Wiih limited exposure, it is easy
lo miss such an injury. lf you suspect a hoLe you can 1 see' nere aro your
opl ions:
a Contralateral neck exploration through a separate incsion'often your
a Intraoperatve esophagoscopy lo look for an iniury lrom inside ihe
lumen,
a Mobllize theesophagus by bluntly developing the plane between it,
the tfachea anieriorly, and the anterior longitudinal igaments
posteriorly. Hook your finger (or a Penrose drain) around it and
inspecl the contralateral and posteriof aspects However, this
maneuver s more dltficult lhan our description leads you to believe'
especialLy if you ate trylng to do il thro!gh a right-sided neck incision
Unless you have deceni experience with esophageal surgeryi don t
use lhis option. You may cause iairogenic iniury to the esophagus and
fecurrent laryngeal nerves, as well as devascularize the irachea
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TOP KNIFE lhe Ad & Croft olTroumo Surgery
Regardless of the option you choose, the key tacucal princip e is io be
sure about the hidden aspects of the esophagus before conclud ng youf
exDtoTaIlon,
Worry about the hidden aspects of the esophagus
After identifying an esophageal injury, careiully assess the extent of
damage. [,4ucosal damage is ofien more extensive than ihe apparent injury
lo the muscularis. Conservatively debride the wound to obtain healthy
edges on all sides and repair it using one or lwo ayers, Our preference is
a single layer repa r using an absorbable monofilament suture, [,/uch more
impodanl than the number oi layers ls precise definlton and meticulous
aDoroximation of the mucosal deiect witholt tens on.
Always isolate your esophageal repair from oiher suture Ines. lf you
have also fixed ihe caroiid adery or the irachea, remember that the
esophagea repa r s the one mosi ikely to fa L When il fails - lt may take
your other repa rs wih it. Don t et it happen. lnierpose a well'vascu lar zed
chunk of healthy rnuscle between the esophag!s and any adjaceni suture
lines. The strap musces, ornohyoid or slernal head of the SCM can each
be transected close to their inferior attachmenis and ihen used to keep
vour suture lines safe v aoart.
Whal is ihe danrage control optior for the cervical esophagus? Srnce
the aim is to prevent an uncontrolled eak, the bail oui soluton ls exterral
drainage. l f the injury is naccess ble (e.9. high or poster ior in the
hypopharynx), just drain t. lf there is no distal obstrlciion, the fisiula wil
rapid y close.
When you cannot safely close the deiect because it is loo large, the
operaiion was de ayed, or you have to bai out, either drain or exteriorize it
as a latera esophagostomy. This s pariicuLarly relevanl when you
encounter combined njurles to the esophagus and lrachea, where
creat i fg two high-r isk suture lnes is asking for t roube. Repair ing the
airway and divertrng ihe esophagus may be a safer option.
A quick and easy bail out optior that has worked for us is to rnserl a
lafge suctjon drain irio ihe defecl, rapidly purse'siring the esophageal wall
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Bail out by creating a controlled esophagealfistula
14 The Neck Sofori in Tiger Counlry
around it and bring ii out ihrough the skin Whatever you choose as your
damage control solution, fememberl an uncontrolled esophageaL leak
means mediasiinitis and death; a controlled flstula means a longer hospLtal
stay with a good chance ot recovery
The larynx and trachea
lnjuries to lhe upper airway come in two lypes: small and large Repair
small aceralions of the larynx and trachea with interrupted 3:0
monofilament absorbable sutures tied on lhe ouiside Never use non-
absorbable sulures to repaLr the alrway.
Large defecis cannot be simply approximated withoui ienson because
part of ihe cariilage is missing. To obtain a good outcome' you are well
advised to gei early help ffom an ENT colleague They have more
experience with the upper airway and will ultimateLy rnanage any
complicatlons.
Several damage control oplions for uppef airway inluies are availabl-".
You can simply push ihe endotracheal tube Past the injuted area to
eliminate the air leak, leaving the injury alone fof a delayed reconstruciion
Another oplion is tracheostomy. Inserting a itacheostomy tube through a
traumatic tracheal defect is not a good move under elect lve
circumstances. li is, however, perfectLy accepiable as a bail out option
when the pat ient has other i fe-threatening iniures, orwhenyou ate facing
a comp ex Inlury on your own.
Transcervical iniuries
How should you approach a peneirating injury that crosses the neck
from sldeio-side? Transceruica! injuries may require biLaierd expLoraiion
Ruling out an injury to the oiher slde of the esophagus or trachea by
ir t faoperai ive endoscopy, whi le iechnical ly possible, is logisi ical ly
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TOP KNIFE The Ari & Croit of Tfaumo Suraelv
To explore a transcervical
penetration, we prefer a lJ
ncjsion, the ceryica equivalent
of a clam-shel thoracotomy. lf
you spend a few minutes
deveoprng a superror skin fap in
the subplaiysma plane (as you
would do in a thyroidectomy),
you gain maximalexposure of ihe
bilaieral neck, mlch like ifting
the hood of your car to look ai
lhe engine. Exposure just
doesn't get any better than this.
Lift the hood off the neck with a U incision
Finishing up
Have a good look at the edges ot your ncision in search of superlical
bleeders. In the neck, a smal muscular bleeder can easily lead to a
postoperaive expanding hematoma and the need for urgent re-
exploration, Inspect your suture lines and make sure they are nicely
separated by viable muscle.
We strongly advise you dra n every neck exploration {or lrauma using a
closed suction drain. The mosi commonly mlssed injury in the neck is a
small esophageal perforaiion. Your dra n will conved a poientlal disaster
inlo a minor problem. Jf drain ng an esophageal suture l ine, br ing your
drain out anierorly wiihout crossing over the caroiid artery'drains have
been known to erode into lt. The only ayer you have to approximate deep
to the skin is the plaiysma. Then cose the skin and you have successfuly
compleied your safari in tiger country.
\ - l
\\.r11
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I
I
t
14 Jhe Neck Sotari in Tigea'CoLtniy
)
)
)
)
)
)
)
)
)
) Lift.the hood off thensck with a U incision
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TOP KNIfE lhe Art & CrclJi of lroumo SLJrgery
Chapter 15
Peripheral Vascular
Trauma Made Simple
Eoerything shoulil be fia ile as
simple as possible, but not sirftpler.
- Alberi Einstein
li you think you know whai a bloody mess looks like, a close encounter
with a hosing groin wi I have you think aga n The patient is n shock, with
most of the bLood volume eilher lelt at the scene or all over ihe paranredlc
compressing the bleeding gfoln for dear life. Since ihls is one oJ the most
spectacular penetrating injuries, ii is easy to forgei priotities, r.ake critical
errors, and lose ihe patlenl in the midst of the chaos
In ihis chapier we try to bridge the wide gap between the neat
ilustrations of vascular exposures you see n books and the harsh teality
of the OR, where the paiient is bleeding and all you can see in ihe
operative field is tfaumaiized muscle and lots of hernaloma. Bridging th s
gap is especially important for surgeons who don t do periPheral vascular
work on a regular basis but are called upon to conifo and repair the
occasional arterial injury. Our key message is that the injufed artery is
always part of a wo!nded patienl, and the patient's overalltrauma burden
oflFn orcraies 1ow yoJ approach lhe vdscu ar 'njury
Caining control of the hosing groin
Obtain iemporary control of ihe bleedlng groin wiihlocal pressure
applied by an enthusiasiic assistani or a Foley calheter in the tract Once
in lhe OR, you need proximalconlroland have three opt ions:
i Laparoiomy - if there is urgent indicaiion, go into the abdomen and
control the ertFrnal iliac anery in the pclv;s
TOP KNItE The Ari & Croft of Trouma Surgery
a Reiroperitoneal approach -
expose the exiernal i|ac
artery through an obljque
lower abdor. inal lnclsron
approxrmately 2cm above
a.d pafal lel to the nguinal
l igameni. Incise the apo-
neuroses of the external and
internal ob|que, and open
the iransversls abdominis
and transversalis fascia io
expose the preperitoneal fat.
Gentle cephalad retraction of
the peritoneal sac will bring
you to lhe external iliac
artery. This approach avoids
laparotomy, but takes time,
so is farely used in the
bleeding patieni.
a Verticalgroin inclsion - the simplest way to gain p roximal control of ihe
nosrng grorn,
So much for the good news. The bad news is that even with proxima
control, the paiient continles to beed, albeit at a slower rate. lf back
bleeding is noi very brisk and you can identify the key structures, use a
combinaton of sharp and blunt disseciion lo expose the fer.ora vessels.
Blunt disseciion is saler in hostile terriiory. You want to avoid damage to
the femora nerve, and yo! cannot cut the femoral nerve wiih your finger
lf you can t see what you're doing because ol brisk back bleeding, walk
the camps (Chapter 9). The solrce of persistent back bleed ng is often
the deep femoral artery that must be identifed and controlled. When you
succeed, breath a sgh of relief; you have successfully deat with one of
the cobras oi traurna sufgery.
Gain proximal control of the hosing groin
l5 Peripherol vsscu o. Trounro Mode Simple
A quick tour of the femoral tdangle
You are pfobably {amiliar with
the femoral triangle from visrts 1o
lhe groln in elect ive vascuar
procedures. Make a vertical skin
incision over the femoral pllse, if
present. otherwise, place yout
incision halfway between the
pubic tubercle and the anterior
superior lliac spine. Approximately
one-third of the incision should
extend above the gfoin crease
This is not the time to be hesLtant
or minimally invasive.
Exposing the femoral vessels in a
war zone is not easy. You have to
identify and incise iwo fascial layers:
the fascia lata and the femora
sheath. Cut lhe {ascia lata
longitudinally lo enter the fat of the
femoral triangle and insert a self-
retaining retractof. Your best friend in
the hosi i le groin is the inguinal
l igament, and the exPerienced
surgeon makes a poinl of idenii{ying
t early. Palpale the faity content of
the triangle with an educaied Iinger
Feel for a pulse or, if absent, for a
tubular structure in the fai ln the
pulseless groin, you often encounter
muscle beneath the fascia lata. This
simply means thai you are too latera,
over the iliopsoas muscle, so redireci
your dissection medial )/
The inguinal ligament i5 your only friend in a hostile groin
TOP KNIFE The Art & Croft of Troumo Surgery
Next, open ihe femoral sheaih io jdentify ihe femorat artery. Reposition
ihe self-retajning retractor at a deeper level or add another retractor. Stay
on top oi the artery in ihe pedadventitial plane. lf you deviate r.edially, you
may be greeted by a gush of dark blood from the fer.ora vein. If vou strav
laterally, you may injure the lemorai nerue.
lsolaie and control the
common lemoral artery and iis
branches. While the common
and superf ic ial femoral
arter ies can be readi ly
identified and encircled in the
proxmaland distalparts of the
incision, isolat ing the deep
femoral artery can be difficuli
for surgeons with few 'groin
hours. ' The lateral femoral
circumflex vein is ihe most
keacherous vein in the groir.
It crosses immediately in froni
of the proximal deep femoral artery in ihe crotch between the deep and
supedicial femofal artery. lf you try to expose the deep femoral artery by
unroofing it, you soon encounter brisk venous bleedino lrom ihe iniufed
vein. Avordils-rhis ;i6;iJiiiiruaTioi-ii rar'tctei ihan tryirg to.ix ir. oo
not disseci out the deep femoral artery, plain and simptel
The origin of the deep
femoral artery is marked by an
abrupi change in the drameter
of the common femoral artery.
Take a vessel ioop and pass
one end from lateral to media
underneath the common
femoral artery weli above ihe
bifurcation. Grab the other end
of the loop and pass it from
medial to lateral well below the
bifurcation. Lift up both ends of
I 5 Perlphero Vosc ulor Troumo Mode sim p e
the loop io discover thai you have neatly isolated the deep femofal afiery
without dissecting it out
Getting aro!nd ihe groin is r.ore difficult in the presence of a szeable
hemator.;. We call it a hosiile groin, and when you come face_to_face wiih
it, you willsee why. The anatomy is distorted' the tlssues are suffused with
blood, and a bu ging hematoma is look ng up at you in toial defiance
Here, we would like io lei Yotr
ln on a litlle trade secrei Forget
lhe femoral vesselsl Instead,
focus on f inding ihe inguinal
ligameni. lt sounds crazy _ blt t
works. The inguinal ligament s
an anatomical barrier {ChaPler
3), and i{ you ldentiry the lower
edge of the ligameni and cul ii,
you willfind yourself in the virgin
lower reiroperitoneum. Now,
you can easlly ideniify ihe
exiemal iliac vessels immediaiely
above the groin.
There is, however, a less destrucilve way
to clamp lhe femoral vessels above the
inguinal gameni. Take blunl Mayo sclssors
and make a hole in the inguinal ligameni
approximately 1_2cm above and parallelio iis
edge. lnseri a nafrow dsep reiractor io keep
the space open. This brlngs you into the
hematomaJfee retroperiioneum wLthout
dividing ihe inguinal ligament You can now
use ihis hole io easily palpate and sa{ely
carnp lhe externalllac ariery above the groin.
Allthis is very cool, bui if you are pressed ior
iime and ihe groin is aciively bleeding, don t
Don't dissect out the deep femoral artery
TOP KNIFE The Ari a Croft of I roumo Su gery
hesfiate to cut ihe inguina] Iigament. lt is a small price io pay for expedieft
prox mal conlrot,
Control the common femoral artery through the inguinal ligament
Considering youl options
As in any other operation for trauma, you now have to choose an
operative profile. Consider ihe patieni s ovefall trauma burden and
phys ology, as well as the operative circumsiances (Chapter 1). Are you
operatrng rf a university trauma center or in an mprovised field hospital n
a war zofe? How comfortable are you with vascular work? Balance all
these against the feparf optrons.
Darnage coniro options for ihe femora vessels are temporary shunting
or ligaiior. A temporary shunt i. the common or superficial femoral artery
is an excellent damage conirol so ution to maintain distat perfusion. We
strongly recomr.end you do a pre,emptive fasciotomy to give the leg
added prolectron in case of early shunl fallufe (Chapler 3). On v6ry rare
occasions when a shuft is not an opUon, ligating the lemorat artery is a
valid aiernatve. In fact, you can igate the slpedicial femoral artery in a
young healthy paiient with low risk of llmb loss, pfovided collateral
ciculation via the deep femofal artery is irjtact. In the greai nraioriiy of bail
out siluations, a shunt is a nruch better option.
When operai ing ln damage controlmode, f ix the femoralvein only i fyou
can get away with a simple latera repah Don t hesitate to ligate ihe vein
if the injury req!ires an),thing rnore elaboraie.
Shunt + fasciotomy = bail out fo. femoral artery iniuries
Preserving the deep fenroral artery when possible, is an impodant
principle. Your ability to reconstruct ihe bifurcation depends on your
vascu ar expefence and technical repertoire. One welfknown trick in the
r5 Perlpherol vosculor Troumo Made slmpe
face of extensive damage to
the bifufcation is to join the
stur.ps of the superflcial and
de6p femoral arteries side{o-
side to create a short common
arterial trunk before insertingan nterposlt ion graft . This
spares you the awkward job of
implaniing the deep femora
artery lnto the gra{i.
lf the posterior wall of ihe
injured ferioral artery rs iniact,
do a patch repa;r lf the artery
is transected, in ierpose a
synihetic grajt or a reversed
saphenous vein fror. the oiher
leg. lf the arterial and veirous suture lines afe immediately adjacent,
interpose viable muscle belween them to prevent an aitoriovenous fisiula
We do not lnsert iniePosition grafts lnto the femoral vein, but many
surgeons oo.
Whatever yo! do to fx ihe femoral vessels, plan your reconstructLon
wilh soft iissue coverage in mind lf you cannot cover the arterial
reconstructon with well-vasculariz€d soft tissue (e,g swinging the
sarioriLrs muscle over the repait), call someone who can An exposed
arterial suiure line is a ticking time bomb that will blow up in vour tace
An exposed vascular suture line is a ticking time bomb
The superficial femoral afiery
Not surpris ngly, a descr piion of superficial femoraL art6ry exposures is
not found ir most vascular surgical atlases because it is rarely lsed in
electve surgery. Here's how it's done.
I
A , A
TOP KNIfE lhe Art & Crofl of Trourao Suoerv
Sl ight ly f lex and
externally rotate
the pat ieni 's eg,
supportrng t on
folded towels. When
working above ihe
knee, support ihe
leg below the knee to avoid disiorling your work space. Make a longitudinal
incision over the anterior border ol ihe sartorils muscle, extending it well
proximalto the injury. lncise the skin carelully to avod accidentally transecting
the saphenous vein. Open
the superficial fascla and
identify the sartorius
muscle, the gaiekeeper of
ihe super{ ic ial {emoral
artery. Retract ihe sadorius,
eithef anieflorly (in the
upper and niddle ihigh) or
posterrorly (in the middle
and ower thigh), by
insertlng a self.retaining
retractor nto the wound.
Your target ls the flbrous
roof of Hunter s canal, the
white fascia directly underneath the sartorius between the adductor
magnus and vastus medialis muscles. Open il and you are staring at the
neurovascular bundle. Carefully free the superficial femoral artery from the
adjacent vein and pay
special atteniion to the
saphenous nerve that Ls
pad oi the neurovascular
bunde and can be easi jy
damaged. As with any
vascu ar Injuryi $an your
dissection ln v rgin terriiory
proximal to the injury and
proceed disialy toward
the injured segment.
What are your repair optons? YoLl may elecl to insert a shunt if you
need to bail out or if you decide (with ihe orihopedic surgeons) to achleve
bone alignment prior to arterial repair. This is genetally a good idea since
sewing a graft in an unslable flailing lir.b is something yo! should avoid lf
possible. When the superficial femoral artery is iransected' Insert an
interposition graft.
The sartorius is the gatekeeper of the superficial femoral artery
Popliteal repaks the easy waY
Treat the popliteal artery wiih the resPect it deserves lt is the leasl
accessible vessel in the lower ex?emlty, and ihe collaleralflow around the
knee is insufficenito sustain viability ofthe lowef leg ifflow in the popliieal
artery is inierrupted- Even ioday, poplitea artery trauma catries lhe h ghest
inb loss rare o'ale\kemry vascuar nrures.
Always begin a popliteal repair with {asciotomy, even il you are an
exiremely smooth operatof. lf there are no associated lnjuries ihat may
bleed, give systemic heparin. [/any pop iiealrepairs fa because ol cotted
dista mlcrocirculation, not because of a technlcalflaw
Treat the iniured popliteal adery with the greatest respect
The safe and sound
route to ihe injured
popliieal artery is the
medial approach. Make
an incislon in the lower
th gh along the palpable
groove belween the
vastus medials and sart-
orius muscles. Palpate
l5 Peiplrero Voscu or Troumo Mode Simp e
the posterior border o{ ihe femur and incise ihe deep fascia posterior to ii,
bringing you s?aight into the fatiy contentofthe popliteal lossa. lnserl a finger
and palpate the pulse of ihe popliteal artery againsi the posteior aspect of
TOP KNIfE The Ari & Croii of Troumo Surgery
the fe.nur The posterior
edge of lhe bone is the key
anatomical landmark to
identify ihe popliteal vessels,
both above and below the
knee. Now ideniify, dissect
out, and enc fcle the above.
knee popliieal artery. The
three major pitfalls in this
dissection are injuring lhe
closely adherenl popliteal
vein, cutling the saphenous
nerve, and mislaking the
Find the popliteal artery immediately behind the bone
Expose the distal
Pophteal segment
thfough a sepafate
incision that runs
approximately lcm
behind the border of
the tibia, begrnning at
the level of the knee
rmmediaie y posterior
to ihe medial femoral
Asain, beware of injur ng
the saphenous v€in that lies
imrnediately posterior io your
incision. Cutting lhe deep
fascra reveals the fal of the
distal poplileal fossa, where
you find the neurovascular
bundle immediately behind
the bone. The first structure
15 Periplreroi Voscu or Trou mo Mode smpe
you encounler is the pop iteal vein, and you have to carefully dissect the
ariery away lrom rt.
So niuch for proximal and distal control. But how are you golng to lix
ihe injury itsel{, an iniury that siill remains hidden behind the knee? Well'
you can do it the hard way or the easy way
The hard way is the traditional ful! popliteal exposlre' the one you
should describe in your Board Exam because ihls ls whai examLnerc
expeci to hear. li entais joining ihe medial incisions above and below ihe
knee and dividing the tendinous aitachn-rents ofihe posleromedialmuscles
(sariorius, graciis, semimembranosus' semltendinosus)' as well as the
attachment of ihe medial head of the gasirocnemius ln praciice' grab the
cauiery and blaze a trail oJ destruciion between your proximal and distal
incisions, blasting any iendon ihal stands between you and the poPl*eal
artery. Ii sounds llke a search and deslroy mission because it is Bytheiime
you flnish, it is not a pretty sight, but you can get io the artery and fix it
There is a simpler alternative lnsiead of exposing ihe injured artery,
bypass and exclude it. You akeady have lhe proximaland distal popliteal
segments looped and ready Even if the popliteal veln s injured' ii doesn't
matter, You don t have to reconstruct it io achleve a good outcome The
notion thai yo! do ls jusi another sacred cow that has been slaughtered
by curreni data. Your mosl expedient soluiion is to harvest a pLece oT
saphenous vein from ihe other thigh, teverce ii, and inseri ii as an
lnterposiiion graft belween the proximaL and dista poplitea artery,
excluding the injured segment.
Bluntly creaie an inter_
condyaf iunnel between
ihe proximal and disial
lncisions. Do a longiiudinal
arteriotor.y in the Proximal
popliieal artery above the
knee, hook !p the
reversed vein endlo-side,
and ihen doubLy lLgate the
adery immediatelY distal
TOP KNIFE The A.t & Croit of Troumo Surgery
to the anastomosis to exclude the inlured segment. pass the pusating
graftthrough ihe tunnel, and hook it up to a similar arterioiomy in ihe distal
pop iteal ariery below the knee. Then ligate the artery immediately proxima
to the d stal anastomosis to complete the exc usion, In an obese pattent
with a deep artery, ii is easier to transect the proximal and drstal oopliteal
arreJ. oversew rhe ends o l -F e.ctLdeo <eg-ent. a. ld .hen hoot up -he
vein graft end-io-end.
The huge advartage of this approach is simplicity. you don t have io
deal with the inj!red segment ai all. The on y vatid reason to take down the
ligaments and expose ihe popliteal fossa is ongoing bleeding from the
njufed segment despite exclus on, a s tuaton we nave yet io encounter
Bypass and exclnde the iniured popliteal artery
Below the knee
Reconsiructing a iibial artery in a patieni wiih a blunt bumper injLrry
thai includes a fractured libia and f bula is an experience I ke y to remain
etched n your memory. Imag ne spending the beiter part of an on-callnrght trying to bridge two spastc noodles in a soup of blood, broken
bones, and torn nuscl€s. Answering the following ihree quesiions can
he p make this experience much ess traumatic for you and your patient.
1. ls th s escapade really necessary? One of the rhree leg arieries open
all the way down to the foot rs good enough. The iradiiionai teach ng
that panents with blunt trauma need two open vessels s an
unsubstantiated urban legend. Remember - if one of the three arteries
is beedng, the solution is noi surgical exptoraiion and ligation, b!t,
rather, angiographic occlusion ol the bleeder (unless angiography is
foi ava labe).
2. Do you have the required infofmaiiof for a safe trip? Staring a
vascular explorat ion beow ihe knee wthout a ctear angographic
delineaiion of the inlured segment is tike stading the Dakar Rally
witholt a map. I\,,lake every effort to obtain a formal angiogram. lf you
l5 Pe.ipherol Voscu ar Troumo Mode Simpe
are forced to run to the OR urgenily' begin by exposing the popliieal
artery below the knee and shooting an on_table angiogram A stlb_
optimal angiogram can send you on a lengihy exploration ot what
turns oui to be an intact aitery in spasm
3. Where to begin? The popliieal fossa below the knee ls an excellent
siarting point because you can always {ind the ariery there, even if
you have lilte vascular experience ll is v rgin terrltory, the vessels ate
large, and you can ideniify the neurovascular bundle and follow t
disialy.
Retracl the medial
head of the gastroc-
nemius posteriorly and
expose the edge of the
soleus muscle archlng
ovef the popl i teal
vessels. Hook a f inger
underneath the r.usce
and detach ii trom the
t ibia. This opens the
sPace, alowlng you to
place a self-retainlng
retfactor in the wound.
Proceed distally toward
the injury by taking
down the atlachment of the soleus lo the posterior aspect of the Ubia
Look for ihe anterior tibial vein as a marker of the iake-off of the anienor
tibiaL artery. Further
distaLly, identify the
bifurcation of ihe
tiboperoneal irunk
into the postenor
libial and peroneal
arteries, where the
former is the more
superfic al vessel.
Expose ihe anterior tibial artery ln the mid'and lowef leg ihrough your
anterior fasciotomy incision, lnsert a self-retaining retractor between the
t ibiais aniefor and the extensor hal lucis longus mlscles, and f ind the
neurovascu ar b!nde deep down between the musces, on the
Inlerosseus raemDTane,
Before you begin a vascular exploration below the knee, slrongly
consider us ng a proxima pneumatc iourniquet above ihe knee. Noth ng
is more lrustratrng than trying io identlfy and isolate the small and frag le
vessels of the lower leg in the presence of active bleeding not io meniion
ihe ncreased rsk of ia irogenic njury io other eements of the
neurovascular bundle,
Whch ar iery shoud you reconstruct? Always go lor the most
straightforward so ution n the mosl accessibe ariery and take into
account soft tissue coverage. lMost often, th s lranslates inlo reconstruciing
the poster or libial adery. In a badly inj! red eg, be prepared to spen d som e
time looking for the dstal end of the transected vessel, which may be
dtf icul i 10 fnd. In most instances, your best reconstruct ive opt ion is an
interposition graft using a reversed saphenous vein frorn the other ank e.
TOP KNIFE The Ad & Croli of Troumo Surgery
The axillary artery
To gain rapld access io the,4&iy," ^,--
proximal axilary artery, you have io ;r;1 ,r 1, ,.a^or)
go ihrough the pectorais major
muscle. Abduct the arm and make
an nfraclavlcular incsion extending
from the mid-clavicle io the
deltopectoral groove. This trans-
pectoral rouie is an extens le
exposure. You can extend it distally
along lhe del lopectoral groove.
Dissection between the delioid and
ihe pectoralis r.ajor, comb ned wilh
One open t ibialartery is good enough
i) ,-.4-' -
lateral revactlon of ihe cephalic vein, will reveal the clavipectotal fascra
containing the neurovascular bundle Fudher distal exienspn Into the
groove between the biceps and the tticeps muscles will get you to the
proximal brachial adery
Cul down io the
pecioral lascia, divide
it, and then spread the
pectoralis major fibers
by insedrng closed
Mayo scissors inio ihe
muscle and oPenjng
them pefPendicular to
ihe fibers lo nrake a
hole. Underneath you
find the pectotalis minor
and the claviPectoraL
fascia medialto ll. OPen
r5 Peiphera voscuarlroumo Mode simp e
.|trr.",r..*,J 
,,,y
' q ' . l . J l r - , - i l - ^ r
the clavipecloral fascla
and dlssect ln the axilLary fai to identify the axillary vein, the gatekeeper o{
lhe ar l la. Tl^e anery is oeep and supet ior Io i t To opt 'nize you'worl
space, get the pectoralis mlnor muscle oui of the way either by retractrng
ii lateraiLy or dividing its upper aitachr.ent 1o ihe coracoid process To
safely mobilize the axillary artery, you musi fitst identify' clanrP, and cui the
thoracoacfomial artery, one o{ the only arterial bfanches in the body io
come siraight at you when exposing the pareni vessel
Your damage conhol opiions for axillary artery iniuries are shunt
insertion and, less commonLy, ligation and fasciotomy Ample collaterals
around ihe sho!lder wilL prevent critical distal ischemia in most patienis
wrh an ir .e Jpted ar i ,a-y alery but rFuonstrLcion rusng a saohelors
vein gra{i hawesied from the ihigh) is a betier option if {easible
Approach the axillary artery through the pectoralis major, not around rt
)-'., 
.,;,..,
TOP KNIfE The Ad & Crofl of Tro!mo Surgery
The brachial artery
The brachial airery s the most
frequently injured artery in the body
and certainly one ol the most
accessib e, Gain access to the
pfoximal artery via a medal upper
arm incision along the groove
between the brceps and tr iceps
muscles. This incision sthe epitome
of extensile exposure, as it can be
easiy extended both pfoximally nto
ihe de topectoral groove and d stally
across ih€ antecub talfossa inlo the
forearm. Incise the deep fascia at
the media border of the biceps,
i t r . \ . v . / -
taking care to avold
iairogenic lnj ! ry to the
basiic vein as it emerges
ihrough ihe fascia in ihe
lowef aspect of the
incision. Antefror retraction
oJ the brceps will expose
the neurovasc!lar bundle
enveloped in the brachial
sheath. The f rst siructure
you encounter (and your
landmark) is the median
nerve. Retract it genlly to
get t oui of your way.
Distal extension of the medial arm lnclsion rs vra an S-shaped ncrsion
carried across the antecubital space disia to the skin crease. The distal
brachial artery and its bifurcation are located immediately beneath ihe
biceps tendon, again rn cJose proximiiy to the median nerve.
The damage control option lor the brachial adery is ligation and
fasciotomy, which is very welliolerated, espocially i{ the iniury is in the mid_
or distal arm beyond to the take'off of the deep brachial artery The
oefntve repair opton s a veir interpos:t ion gtaft Jsing the sapheroLs
vein harvesied above the ankls.
T H E K E Y P O I N T S
) Gain proximal conirol of the hosing groin
) The inguinal ligameni is your only friend in a hostile groin'
> Don'i dissect out the deep femoral arterr'
) Controlihe common femoral artery through the inguinal ligament
) Shunt + fasciotomy = bail out {or femoral ariery injuries
) An exposed vascular suture line is a ticking lime bomb'
) The sartorius is ihe gatekeeper of the superficial femoral artery'
) Treat the injured popliteal artery with lhe greatest respect'
) Find the popliteal artery immediately behind the bone'
) Bypass and exclude ihe injured popliteal artery
) One open tibial artefy is good enough.
) Approach the axillary artery through the pectoraiis major, not around t
I5 Peiplrero Voscu or Troumo Mocle simp e
'* 
ll
	Top Knife.pdf
	Contents
	Section I - TOOLS OF THE TRADE
	Chapter 1- The 3D Trauma Surgeon
	Chapter 2- Stop That Bleeding !
	Chapter 3- Your Vascular Toolkit
	Section II - THE ABDOMEN
	Chapter 4- The Crash LaparotomyChapter 5- Fixing Tubes: The Hollow Organs
	Chapter 6- The Injured Liver: Ninja Master
	Chapter 7- The "Take-outable" Solid Organs
	Chapter 8- The Wounded Surgical Soul
	Chapter 9- Big Red & Big Blue: Abdominal Vascular Trauma
	Section III - THE CHEST
	Chapter 10- Double Jeopardy: Thoracoabdominal Injuries
	Chapter 11- The No-nonsense Trauma Thoracotomy
	Chapter 12- The Chest: Inside and Out
	Chapter 13- Thoracic Vascular Trauma for the General Surgeon
	Section IV - THE NECK AND EXTREMITIES
	Chapter 14- The Neck: Safari in Tiger Country 
	Chapter 15- Peripheral Vascular Trauma Made Simple