Trauma, 7th Ed.

ATLAS OF TRAUMA

Introduction to the Atlas

Head and Neck

FIGURE 1 Nasal Packing for Hemorrhage Control

FIGURE 2 Steps in Performing a Lateral Parietal Craniectomy

FIGURE 3 Anatomy of the Neck

FIGURE 4 Alternate Neck Incisions

FIGURE 5 Repair Techniques for Injury to the Common Carotid Artery Proximal to the Bifurcation

Thoracic Outlet and Chest

FIGURE 6 Alternative Approach to Interposition Grafting for an Injury to the Proximal Internal Carotid Artery

FIGURE 7 Repair of a Combined Injury to the Trachea and Esophagus

FIGURE 8 Control of Injured Vertebral Artery

FIGURE 9 Tube Thoracostomy, the Most Commonly Performed Thoracic (Operative) Procedure

FIGURE 10 Thoracic Incision Options

FIGURE 11 Technique for Performing Median Sternotomy

FIGURE 12 Median Sternotomy With a Neck Extension for Access to the Left Proximal Common Carotid Artery Injury

FIGURE 13 Opening the Pericardium to Explore the Heart

FIGURE 14 Cardiorrhaphy

FIGURE 15 Pulmonary Tractomy

FIGURE 16 Anatomy of Left Pulmonary Hilum

FIGURE 17 Anatomy of the Right Pulmonary Hilum

FIGURE 18 Controlling Intercostal Artery Bleeding

FIGURE 19 Exposure and Management of Innominate Artery Injury

FIGURE 20 Controlling Hemorrhage From the Subclavian Artery

FIGURE 21 Exposure and Repair of a Subclavian Artery Injury

FIGURE 22 Anatomy of the Thoracic Duct

FIGURE 23 Cross-clamping of the Thoracic Aorta

FIGURE 24 Left Heart Bypass

FIGURE 25 Hilar “Lung Twist”

Abdomen

FIGURE 26 Pelvic Packing for Grade 5 Fracture With Retroperitoneal Bleeding

FIGURE 27 Liver and Biliary Anatomy

FIGURE 28 Hepatorrhaphy

FIGURE 29 Tractotomy

FIGURE 30 Liver Omental Packing

FIGURE 31 Hepatic Balloon Tamponade

FIGURE 32 Liver Packing

FIGURE 33 Pancreaticoduodenal Biliary Anatomy

FIGURE 34 The Pringle Maneuver

FIGURE 35 Pyloric Exclusion

FIGURE 36 Division of Pancreatic Neck to Expose the Portal Vein

FIGURE 37 Distal Pancreatectomy

FIGURE 38 Kocher and Cattell–Braasch Maneuvers

FIGURE 39 Atrial Caval Shunt

FIGURE 40 Exposure and Repair of Injury at the Esophagogastric Junction

FIGURE 41 Celiac Axis Bleeding

FIGURE 42 Mattox Maneuver for Large Central Suprarenal Retroperitoneal Hematoma

FIGURE 43 Repair of the Transected Ureter

FIGURE 44 Temporary Abdominal Wall Closure Following Damage Control Laparotomy

FIGURE 45 Secondary “Damage Control” (if needed)

FIGURE 46 Tertiary “Damage Control” (if needed)

FIGURE 47 Closure for Prior “Damage Control”

Vascular

FIGURE 48 Small Vascular Anastomoses

FIGURE 49 Deliberate Division of the Right Common Iliac Artery

FIGURE 50 Temporary Vascular Shunt

FIGURE 51 Complex Femoral Artery Reconstruction

FIGURE 52 Popliteal Artery Injury Behind the Knee

FIGURE 53 Exposure and Repair of Popliteal Artery and Vein Injuries

FIGURE 54 Exposure and Repair of Popliteal and Tibial Artery Injuries

FIGURE 55 Posterior Exposure of Popliteal Artery Injuries

FIGURE 56 Calf Fasciotomy

FIGURE 57 Forearm Fasciotomy

FIGURE 58 Venous Bypass

Introduction to the Atlas

Each preceding chapter has figures, tables, and drawings that aid the author and the editors in imparting and clarifying the messages of the chapter. In this edition of TRAUMA, the editors have devoted a special section to an atlas. It is not intended to include an exhaustive artistic rendering of every operation, but, rather, to focus on procedures that are commonly used in major trauma operations, along with related anatomical drawings. Some procedures that may have been commonly practiced in the past but are rarely currently done are not included. However, a few relatively infrequently used concepts and procedures have been included in this section because of sufficient need to clarify the opinions of the editors. The art has been kept in as simple a form as possible, so it is expeditiously available when needed for a quick refresher in anatomy, anatomical relationships, and/or surgical approach in the “heat of battle.”

Head and Neck

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FIGURE 1 Nasal Packing for Hemorrhage Control

A. Under general or topical anesthesia, gauze impregnated with Vaseline to facilitate insertion is layered into a bleeding nasal passage to achieve hemostasis

B. Balloon devices are commercially available to provide posterior and anterior nasal packing

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FIGURE 2 Steps in Performing a Lateral Parietal Craniectomy

A. The exact location and size of the skin flap vary, depending on extent of the wound but must not extend to the midline at the top of the skull

B. Skin clips are placed for hemostasis, and burr holes elevate the skull bone flap

C–D. The bone flap is removed, the dura mater is opened to expose and release an epidural hematoma, and bleeding vessels are ligated. In the absence of significant brain swelling, the skull plate is reattached once hemorrhage is controlled and other necessary procedures have been accomplished. With significant brain swelling, the dura is closed, sometime using dural substitutes, and the bone flap is not replaced at initial operation (decompressive craniotomy)

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FIGURE 3 Anatomy of the Neck

A. Anterior Perspective—Although usually approached from incisions just anterior to the sternocleidomastoid muscle, the surgeon must always review the cervical anatomy and its structural relationships prior to incision. The external jugular vein is a subcutaneous structure, and the internal jugular vein and carotid arteries are deep and medial in the neck

B. Lateral Perspective—The proximal sternocleidomastoid and scalene anticus muscles cover the proximal extrathoracic subclavian artery. Not shown are the almost invisible thoracic ducts (both sides of the neck) that enter at the lateral superior junction of the internal jugular vein and the subclavian vein

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FIGURE 4 Alternate Neck Incisions

A. For thoracic outlet injuries (Zone 1 cervical injuries), median sternotomy may be combined with either a right or left classic anterior neck incision, which allows for proximal vascular control

B. For injury to the proximal extrathoracic subclavian artery, supraclavicular extension of a median sternotomy allows for proximal control as well as exposure, should division or removal of the clavicle be required for exposure and repair of the injury

In some instances, such as an injury to the proximal left carotid artery, it is necessary to extend the median sternotomy into an anterior neck incision

C. In some instances of bilateral neck injury, a bilateral anterior neck incision may be made separately or joined to create a skin flap to expose the entire anterior neck

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FIGURE 5 Repair Techniques for Injury to the Common Carotid Artery Proximal to the Bifurcation

A. The injured vessel is debrided after proximal and distal control is obtained. Local heparinized saline is injected distally

B. If the injury is not extensive, end-to-end anastomosis with 5 (0) polypropylene running suture using a “parachuting” technique is possible. Note, with adequate arterial collateral circulation, a temporary carotid artery shunt is not required

C. If the artery is going to be under tension or stretched, an interposition graft of Dacron (shown), polytetrafluoroethylene (PTFE), or scavenged vein is inserted

Prior to completely releasing the clamps and before prograde flow is reestablished to the brain, any microclots that might have formed during the procedure are adequately flushed out, both proximally and distally

Thoracic Outlet and Chest

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FIGURE 6 Alternative Approach to Interposition Grafting for an Injury to the Proximal Internal Carotid Artery

A. Following proximal and distal control and instillation of local heparinized saline, the area of injury is resected, and the external carotid artery is mobilized for a distance sufficient to bridge the gap for the injured internal carotid artery

B. The origin of the proximal internal carotid artery is oversewn, and one anastomosis is accomplished using the mobilized external carotid artery branch to beyond the injury on the internal carotid artery. Ligation of one or two branches of the external carotid artery may be required to accomplish significant mobilization

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FIGURE 7 Repair of a Combined Injury to the Trachea and Esophagus

A. Following repair using interrupted absorbable sutures on the trachea, a vascularized muscle pedicle (such as the sternal head of the sternocleidomastoid muscle) is interposed between these two tubular structures to reduce the postrepair complication of fistula formation

B. The procedure demonstrated in cross section

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FIGURE 8 Control of Injured Vertebral Artery

A. The vertebral artery lies deep in the neck inside the transverse foramen of the cervical vertebra. For uncontrolled bleeding from an injured vertebral artery within the transverse foramen of the neck, dissection and unroofing of this bony covering can be difficult and even produce additional injury and complications

B. Bone wax pressed into the area of bleeding can rapidly control persistent bleeding

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FIGURE 9 Tube Thoracostomy, the Most Commonly Performed Thoracic (Operative) Procedure

A. The lateral anatomy in the auscultatory triangle at the fourth intercostal space in the midclavicular line is the point for chest tube insertion

B. Following adequate anesthesia, skin incision, and dissection of subcutaneous tissue are accomplished, and a large clamp or dissecting scissors are used to spread the intercostal muscles. The pleura is entered with the probing finger. Up to 25% of patients have some element of pleural symphysis, and entering the pleura with a Trocar or other similar instrument risks producing an iatrogenic lung injury. The finger allows digital exploration to discern the pericardium or a diaphragmatic injury and/or release pleural adhesions

C. After an appropriately sized hole is created, a chest tube is introduced with the aid of a large curved clamp attached to the tip and directing the tube to the posterior apex location of the pleural space. The tube is attached to an appropriate collection, water seal, and negative pressure device

D. The chest tube is aimed toward the apex of the pleura, with the last hole in the tube inside the chest wall

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FIGURE 10 Thoracic Incision Options

A. The median sternotomy is the standard incision for anterior cardiac and thoracic outlet vascular injury, but is not an appropriate incision for approach to posterior mediastinal structures or the pulmonary hilum

B. A median sternotomy with an anterior neck or supraclavicular extension is used for thoracic outlet great vessel injuries to Zone 1 of the neck

C. The anterolateral incision, particularly on the left, is the utility emergency thoracotomy for trauma and resuscitation. It is made from the sternal edge, under the mammary fold, and in a curvilinear fashion toward the axilla, staying in close proximity to the fourth or fifth intercostal space. This incision should not be a straight line incision nor be carried through the female breast

D. Bilateral anterolateral incisions may be either separate or combined and transternal. When transternal, the sternum is traversed with a Gigli saw or other cutting device, and the internal thoracic arteries are ligated on both sides on the upper and lower incision sites (four ligatures). Both incisions should be curvilinear, with the transternal cut high enough on the sternum to expose the mid-portion of the heart and also with sufficient sternum to accomplish a solid bony closure. On occasion, when a right-sided injury is suspected high in the pleural cavity, the incision might even be above the right nipple

E. In the female, the anterolateral incision is at the inframammary fold and is accomplished by moving the breast tissue cranially

F. With the patient in a lateral decubitus position, a posterolateral fourth or fifth interspace incision can be made from near the area of the nipple, laterally around to near the spinal canal. This incision for trauma traverses the latissimus dorsi muscle and portions of other chest muscles. The scapula must be retracted superiorly to achieve fourth or fifth interspace incisions. This incision provides exposure of posterior mediastinal structures, such as the aorta, lung hilum, esophagus, trachea, and azygos vein

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FIGURE 11 Technique for Performing Median Sternotomy

A. With the patient appropriately prepped and draped, a skin incision is made from the manubrial notch to below the xiphisternum

B. Using blunt dissection, the fingers are inserted just beneath the sternum from below and above, carefully dissecting the pericardium and loose fatty tissue away from the back of the sternum

C. Using a sternal saw, keeping in the midline of the sternum, and exerting upward pressure on the saw, the total length of the sternum is cut. Care is taken not to divert to the right or left chest cavity

D. A sternal retractor is placed into the incision, first with the two blades touching each other, and then slowly opening the sternum to avoid fracture of the sternum or any ribs. The pericardium, the thoracic vena cava, ascending aorta, pulmonary artery, and lower neck structures are now exposed. The left innominate vein, in the upper extent of the incision, is enclosed in fatty and thymic tissue, and care must be taken not to injure this vein

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FIGURE 12 Median Sternotomy With a Neck Extension for Access to the Left Proximal Common Carotid Artery Injury

A neck incision or a median sternotomy, alone, is insufficient for control and reconstruction of injury to the left proximal common carotid artery. However, a combined incision, aided by two retractors, affords excellent exposure. The hematoma is often extensive. Note the location of the left vagus nerve, with its recurrent laryngeal nerve, around the aortic arch. Also note the lateral location of the left phrenic nerve. Concomitant venous injury and bleeding is common

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FIGURE 13 Opening the Pericardium to Explore the Heart

Using scissors or a scalpel, the left pericardium is incised, with the lung positioned posteriorly. The incision is made anterior and parallel to the phrenic nerve. With a tense hemopericardium, purchase of the pericardium is difficult, making this maneuver difficult. The ratchet mechanism of the chest wall retractor is positioned posteriorly

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FIGURE 14 Cardiorrhaphy

A. Through a median sternotomy, the tense pericardium is incised in the midline and the clot extracted as digital hemorrhage control is accomplished

B. Cardiorrhaphy is accomplished by simple direct closure of the penetrating wound using 4(0) polypropylene suture. Repair is accomplished prior to cardiac defibrillation. Often, traction on a figure-of-eight suture will cause all bleeding to stop, and the suture is simply tied

C. Some surgeons prefer to accomplish cardiorrhaphy with pledgets, an adjunct probably most useful on the friable left ventricular muscle tissue

D. For injury to the heart, very near a coronary artery, it is possible to use the double needle armed suture to go under the artery with both needles and tie the suture (with or without pledgets) lateral to the injury. For a distal coronary artery injury, simple ligation is sufficient

E. Completed closure and ligated distal coronary artery injury

F. Cross section demonstrating the coronary artery undercircling technique

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FIGURE 15 Pulmonary Tractomy

A. A through-and-through hole to the lung or even a large tangential laceration might be controlled with clamps or a linear stapler. The linear stapler is inserted into the tract, thereby joining the two holes. The stapler is fired and the lung cut, exposing the base of the tract

B. A pulmonary tractotomy can also be accomplished by placing two large vascular clamps through the tract and cutting the lung between clamps. A polypropylene suture is run back and forth under the clamps, and other sutures control the base of the tract in a manner similar to when the stapler is used

C. Persistent bleeding points and air leaks are closed with 4(0) polypropylene suture. This nonanatomic procedure is extremely well tolerated

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FIGURE 16 Anatomy of Left Pulmonary Hilum

The anatomy of the two pulmonary hila are slightly different. Before performing a trauma lobectomy or even pneumonectomy, a review of the related anatomy can reduce catastrophic iatrogenic bleeding and prevent bronchial injury. With the lung displaced posteriorly and inferiorly, the highest structure in the left pulmonary hilum, the main left pulmonary artery, is exposed and then sharply separated from the aortic arch. This artery goes behind the left superior pulmonary vein (draining the left upper lobe), and the artery continues downward, giving off branches to the left upper lobe and then to its terminal branches to the left lower lobe. The left main stem bronchus is behind the superior pulmonary artery. Both the superior and inferior pulmonary veins drain into the left atrium

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FIGURE 17 Anatomy of the Right Pulmonary Hilum

The right lung has three lobes, so the anatomy is different from that of the left lung. To expose either hilum, the pleuras covering the vessels and bronchus are mobilized. The highest vessel in the hilum is the right pulmonary artery, giving off branches to the upper and then middle lobes, and then continuing to the arborization into the lower lobe. The middle lobe bronchus and artery come off the bronchus intermedius and right intermedius pulmonary artery in an anterior fashion. The inferior pulmonary vein is in a similar position to that on the left

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FIGURE 18 Controlling Intercostal Artery Bleeding

A. Bleeding from an intercostal artery, injured by a knife, missile, or fractured rib, can be extremely difficult to expose and control. One approach is a figure-of-eight suture ligation of the bleeding intercostal artery at the inferior border of the rib, where the injury occurred

B. Alternatively, absorbable suture can be used to encircle a rib lateral to the bleeding points, pressing the vessel up against the inferior groove of the rib with the encircling suture

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FIGURE 19 Exposure and Management of Innominate Artery Injury

A. The pericardium is opened vertically via a median sternotomy with the sternal retractor in place to expose the anterior heart and ascending aorta. The source of intrapericardial bleeding must be determined. The pericardial incision extends superior to the ascending aorta near the aortic arch. At the thoracic outlet, note the hematoma, which is encountered with an injury to the innominate artery or vein or proximal internal carotid. In this drawing, the upper limits of the incision are extended into the neck (can be either to right or left of midline) so that the distal control of the thoracic outlet great vessels can be obtained. Note, also, that the innominate vein is in the center of the hematoma

B. A blunt injury to the proximal innominate artery is actually a fracture of the aortic arch intima at the takeoff of the innominate artery. The intima of the innominate artery is rolled up with the presentation of the arterial discoloration and injury appears to be in the innominate artery. Through a median sternotomy with a right neck extension, the ascending aorta, aortic arch, innominate vein, innominate artery, subclavian artery, and right and left carotid arteries are exposed

C. Without systemic heparinization or hypothermia, a Dacron graft is sutured end to side to the ascending aorta. In some instances the innominate vein might be divided to expose the area of injury. A partially occluding clamp is placed on the aortic arch proximal to the takeoff of the innominate artery and another vascular clamp is placed just proximal to the bifurcation of the innominate artery

D. The graft is sutured to the distal innominate artery, taking care to back flush and clear the graft of any clot prior to the completion of the suture line. The aortic plate proximal to the injury is oversewn using two pledget strips

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FIGURE 20 Controlling Hemorrhage From the Subclavian Artery

A. Temporary vascular control is achieved via short anterior third interspace incision with a vascular clamp applied to the intrathoracic left subclavian artery

B. Alternately, control can be achieved using a Rommel tourniquet

Note: In the emergency room, this injury can be immediately temporarily controlled with the tamponading finger or an inflated 30 mL Foley balloon

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FIGURE 21 Exposure and Repair of a Subclavian Artery Injury

A. Although endovascular stent graft options are increasingly being used for injury to the subclavian artery, they are not always available, so direct exposure may be required. With the arm prepped free but positioned at the patient’s side, clavicular division or resection might aid in exposure. A liberal supraclavicular incision is made over the clavicle

B. The bone is exposed using a periosteal elevator

C. The clavicle is divided in its middle portion, and the proximal end may be retracted medially

D. The key to the fossa containing the subclavian artery is to remove the scalene fat pad. The phrenic nerve resides in the middle one-third of the scalene anticus muscle, the lateral half body of which is divided to aid exposure

E. The subclavian artery is extremely fragile, and a saphenous vein is the preferred conduit to use in an open reconstruction

F. Following vascular reconstruction, the clavicle can be reconstructed with orthopedic plating

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FIGURE 22 Anatomy of the Thoracic Duct

At the base of the mesentery, anterior to the abdominal aorta and very near the left renal vein, the cisterna chyli collects lymph from the mesenteric lymphatic channels and carries lymph upward, continuing anterior to the thoracic aorta on to the thoracic outlet, via the lymphatic duct. Other numerous lymphatic collateral channels join this thoracic lymphatic duct, where it bifurcates in the upper posterior chest. Although the left thoracic duct is the larger, a thoracic duct empties into the right superior subclavian vein just as it receives the corresponding internal jugular vein. Note that the thoracic duct is anterior to the subclavian artery and posterior to the subclavian vein. Most injuries to the thoracic duct close spontaneously, but if operative closure with very fine 6(0) polypropylene suture is required. Feeding the patient olive oil or cream at the time of anesthesia induction will help discern specific injury site

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FIGURE 23 Cross-clamping of the Thoracic Aorta

A. With the patient in the supine position, a left fourth or fifth interspace curvilinear incision is made beneath the nipple and breast fold aiming to the axilla. The aorta is clamped higher in the chest, at the proximal descending thoracic aorta, using a spring (noncrushing) vascular clamp

B. Alternately, the aorta may be cross-clamped low in the chest. The lung pushed upward, showing the heart within the pericardium, the phrenic nerve, the diaphragm, and the aorta. The esophagus is seen anterior to the aorta and the spine, with the segmental arteries coming off at each interspace. The aorta is cross-clamped low in the thorax using a spring vascular (noncrushing) clamp

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FIGURE 24 Left Heart Bypass

A. One option in the repair of a transection of the descending thoracic aorta is to use active left heart bypass from the left inferior pulmonary vein to the common femoral artery. This procedure decreases the upper extremity hypertension and increases visceral and spinal cord perfusion associated with simple aortic cross-clamping. Appropriately sized cannulas are inserted using a purse string on the inferior pulmonary vein/left atrial junction, with clamp isolation and a Rommel tourniquet around the upper part of the femoral artery. The cannulas are connected to the active bypass circuit as the aortic repair is accomplished. Use of systemic heparin or heparin-bonded tubing is a surgeon’s choice, but care must be taken to avoid any stasis in the active circuit. Following removal, the arteriotomy is repaired

B. A simple femoral vein to femoral artery bypass is occasionally used as an emergency bypass option

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FIGURE 25 Hilar “Lung Twist”

A. Through a fifth anterolateral thoracotomy, the “lung twist” procedure is accomplished by first sharply dividing the inferior pulmonary ligament, taking care not to injure the inferior pulmonary vein at the upper extent of this ligament

B. With the inferior pulmonary ligament divided, the entire lung can be rotated by moving the upper lobe to the area on top of the diaphragm and the lung diaphragmatic surface to the apex of the pleural space. This maneuver creates a torque with the pulmonary vessels, almost immediately causing a cessation of bleeding. Laparotomy packs are used to secure and maintain the lung in this torqued position until appropriate decisions are made to permanently address bleeding from the hilum of the lung

Abdomen

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FIGURE 26 Pelvic Packing for Grade 5 Fracture With Retroperitoneal Bleeding

A–B. Through a low midline incision, the area of the extraperitoneal bladder is approached, taking care to stay outside the peritoneal cavity

C. Any free blood is removed, and the sides of the bladder are retracted

D. Three laparotomy pads are placed on each side, lateral and posterior to the bladder. The laparotomy pads are left in place as a damage control tactic (to be removed later), and the lower midline incision is closed. Some surgeons also ligate the internal iliac arteries bilaterally. Others recommend leaving these vessels intact to provide a route for embolization should bleeding continue

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FIGURE 27 Liver and Biliary Anatomy

A. This drawing depicts the anatomy of the gallbladder and porta hepatis. Although many variations may exist, review of this area can be helpful prior to operating on an injury in this location

B. This drawing illustrates the vascular anatomy of the liver

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FIGURE 28 Hepatorrhaphy

Using a large, special “liver” needle on an absorbable suture, a deep figure-of-eight suture can stop troublesome bleeding. Sutures should be tied loosely, rather than snug and tight, since the liver swells postoperatively, and tight sutures can cause liver necrosis

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FIGURE 29 Tractotomy

Gross, large ligatures to the liver may cause liver necrosis and postoperative fever. The injury is unroofed by performing a tractomy, with direct ligation of the biliary and vascular structures

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FIGURE 30 Liver Omental Packing

The left side of the omentum is mobilized off of the transverse colon mesentery, preserving a vascular pedicle from the right side of the transverse mesocolon. The sutures attaching the omentum to the liver are loosely applied, so as not to strangulate the omentum

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FIGURE 31 Hepatic Balloon Tamponade

A custom, temporary balloon is fashioned using a Penrose catheter and a rubber catheter, sealing off the ends of the Penrose drain placed over the catheter. After insertion into the body of the liver, the catheter is then filled with saline. Over time, the pressure on the “balloon” can be lost, so that reinflation or a secondary procedure might be necessary following this temporary “damage control” tactic

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FIGURE 32 Liver Packing

Temporary packing of a bleeding liver is the prime example of damage control. Laparotomy packs are placed above and below a bleeding area in the liver, making a “liver sandwich.” Care is taken not to obstruct the inferior vena cava or to produce too much constriction, leading to liver necrosis

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FIGURE 33 Pancreaticoduodenal Biliary Anatomy

The normal anatomy in the gastroduodenal-pancreatic area of the abdomen is very compact, with many adjacent structures. The superior mesenteric vein is usually to the right of the superior mesenteric artery, and the splenic artery is usually near the superior border of the pancreas, while the splenic vein is posterior to the pancreas and covered by this organ. Note, the collateral arterial circulation in the head of the pancreas, which can be a significant source of bleeding

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FIGURE 34 The Pringle Maneuver

Using a noncrushing (vascular) clamp, the entire porta hepatis can be occluded to decrease bleeding from an injured liver. This is a temporary occlusion of the portal vein, hepatic artery, and bile duct. It is accomplished by palpating the Foramen of Winslow and precisely placing the clamp on only the desired structures

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FIGURE 35 Pyloric Exclusion

A. For a complex combined injury to the pancreatic head and duodenum, pyloric exclusion is performed to eliminate lateral duodenal fistula formation, should a duodenal leak occur postoperatively. After control of the injury at the duodenum and pancreas has been accomplished, a dependent gastrotomy is made in the antrium of the stomach. The pylorus is palpated and grasped with a Babcock clamp and closed with the suture of choice. Almost most every suture used tends to cut through the pylorus, and the gastroduodenal outlet reopens in 3–6 weeks

B. Following closure of the pylorus, a dependent anticolic gastrojejunostomy is created. As this is not an ulcerogenic operation, a truncal vagotomy is not necessary

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FIGURE 36 Division of Pancreatic Neck to Expose the Portal Vein

The portal vein is formed behind the neck of the pancreas as the superior mesenteric vein is joined by the splenic vein. Bleeding from this area following penetrating trauma presents an exposure problem. As there are very few sizable veins entering the portal vein from the posterior surface of the pancreas, after the superior mesenteric vein is exposed, a dissecting finger can be placed behind the pancreas, and anterior to the superior mesenteric/portal vein. Using scissors or electrocautery, the neck of the pancreas is deliberately divided over the dissecting finger under direct vision. This exposes the extent to the proximal portal vein, and appropriate vascular control and repair can be accomplished. The cut ends of the pancreas are later simply closed with suture or staples

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FIGURE 37 Distal Pancreatectomy

Whether a blunt transection or a large penetrating injury, if distal pancreatectomy is required in an adult, removal of an uninjured spleen is usually necessary, although occasionally the spleen can be preserved. In this instance, a linear stapler transects the mobilized distal pancreas with the spleen. This area of resection is often drained

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FIGURE 38 Kocher and Cattell–Braasch Maneuvers

A. These maneuvers expose the area of the infrarenal vena cava. With right-sided retroperitoneal injuries, the Kocher maneuver is made by using sharp and blunt dissection lateral and posterior to the duodenum. Retracting the liver superiorly, the peritoneum, lateral to the duodenum, is sharply and bluntly divided, and the duodenum is mobilized toward the left side. The kidney, right renal vessels, and inferior vena cava are left in situ as the portal triad area is brought anteriorly and to the left

B. Exposure of predominately right-sided retroperitoneal vascular injuries can be expedited using a Cattell–Braasch maneuver. First, a Kocher maneuver is performed behind the right colon and lateral to the duodenum, using sharp and blunt dissection. For the Cattell–Braasch maneuver, the Kocher maneuver is extended to the cecum, and then dissection is carried up to the left side of the mesentery attachments, including all mesenteric vessels, with the right colon and small bowel

C. Using this maneuver, the small intestines, right colon and mesenteric vessels can be placed on the anterior thorax, exposing the infrarenal retroperitoneal vascular structures

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FIGURE 39 Atrial Caval Shunt

Isolation of uncontrolled bleeding from the retrohepatic vena cava can be accomplished with an atrial caval shunt. The underlying principle is shunting lower body blood to the right atrium. A large chest tube with an extra hole cut near the base end and clamped at the base is inserted via a purse string suture at the right atrial appendage and advanced into the infrarenal inferior vena cava. Assure the last hole in the tube is below the area of the suprarenal inferior vena cava Rommel tourniquet. A second Rommel tourniquet is placed around the intrathoracic intrapericardial inferior vena cava. Finally, a Pringle maneuver accomplishes virtually total hepatic and retrohepatic vena cava vascular isolation to allow precise repair or reconstruction

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FIGURE 40 Exposure and Repair of Injury at the Esophagogastric Junction

A. High gastric injuries can be difficult to expose and repair. Following mobilization of the left lobe of the liver by lysing the left triangular ligament, the liver is retracted and the esophagus encircled with a Penrose drain for downward traction

B. Anterior holes can be suture repaired, taking care not to cause a stricture at this location

C–D. For an extensive esophagogastric junction injury, the greater curvature of the stomach is mobilized, ligating the vasobrevia vessels, and a fundoplication might be added for a more secure closure

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FIGURE 41 Celiac Axis Bleeding

A. Drawing illustrating injury to the celiac axis

B. Ligation of celiac axis injury

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FIGURE 42 Mattox Maneuver for Large Central Suprarenal Retroperitoneal Hematoma

A. The initial dissection is accomplished by going lateral to the left colon and dividing the line of Toldt, and with blunt dissection, move the spleen, left colon, stomach, pancreas tail, left kidney, and renal vessels and ureter toward the midline

B. The viscera is mobilized to the right by dissecting behind the left kidney and anterior to the psoas muscle. Note that the abdominal aorta is exposed from the esophageal hiatus to the abdominal outlet at the iliac arteries. Care is taken to avoid injury to the left renal artery and vein. The esophageal crux is exposed at the area of the celiac axis, and the left crux can be purposefully cut with scissors and extended laterally across the left diaphragm to expose the distal thoracic aorta to as high as T8. Proximal and distal vascular clamps can be applied preparatory to either lateral aortorrhaphy or interposition Dacron graft placement. The surgeon on the right side of the operating room table is retracting and exposing, and the surgeon on the left is best positioned to perform the aortic repair

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FIGURE 43 Repair of the Transected Ureter

A. Drawing of a transected ureter

B. Spatulated transected ureter

C. Direct repair of transected ureter

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FIGURE 44 Temporary Abdominal Wall Closure Following Damage Control Laparotomy

A. This is the first of a series of drawings demonstrating approaches to management of the abdominal wall after a damage control laparotomy and one in which there is concern for an abdominal compartment syndrome. In this first drawing (44A), a transverse depiction of the abdomen is shown with a plastic drape covering the intestines, a series of cloth packings in the middle of the incision, and a plastic drape covering over the entire abdomen, with this drape resting on the skin.

B–D. In the second drawing (44B) the covering is seen from a frontal view and two suction tubes are seen to emerge from the lower abdomen. Alternatively to the drawings using available pads, plastic sheeting, and suction tubing in every operating room, some surgeons, even at the first operation, might choose to use the same principle, but employ a commercially available device (Numbers 44C and 44D). Other surgeons might elect to use such a commercial device at the second or third damage control laparotomy.

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FIGURE 45 Secondary “Damage Control” (if needed)

A–D. At a second operation, the abdomen is cleaned of any old blood and appropriate secondary operations are conducted prior to application of new plastic coverings over the intestines, new cloth packing, and new plastic sheeting over the packing as seen here on transverse section (45B) and frontal view (45A). Alternatively, a smaller commercial device can be applied (Number 45C and 45D).

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FIGURE 46 Tertiary “Damage Control” (if needed)

A–D. In patients with significant bowel edema it might require subsequent and planned take-back operations where the wound is systematically closed as much as possible as shown using available material (number 46A–B), or commercial devices (Numbers 46C and D).

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FIGURE 47 Closure for Prior “Damage Control”

A–B. When all injuries in the abdomen have been repaired and any abdominal compartment syndrome has resided, the abdomen is formally closed (47 A–B)

Vascular

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FIGURE 48 Small Vascular Anastomoses

A. A triangulated end-to-end vascular anastomoses, a technique initially described by Alexis Carrel

B. Three temporary stay sutures may be tied as each section of the anastomosis is completed. Some surgeons prefer an interrupted anastomosis (not shown)

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FIGURE 49 Deliberate Division of the Right Common Iliac Artery

A. Exposure of an injury to the right common iliac vein is very difficult. Deliberate division of the right common iliac artery between vascular clamps facilitates exposure and repair of underlying venous injury (right common iliac vein, iliac vein)

B. Following venous control, the right common iliac artery is simply re-anastomosed

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FIGURE 50 Temporary Vascular Shunt

A. Used in most major named vessels of the body, a temporary intravascular shunt is pictured here in the common femoral artery. This vascular damage control tactic provides oxygenated blood distal to a vascular injury, while other injuries are addressed or, if necessary, the patient is transferred for a higher level of care

B. Using appropriately sized plastic tubing, that is, commercially available carotid shunts, the shunt is secured with encircling tapes

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FIGURE 51 Complex Femoral Artery Reconstruction

A. Drawing illustrating a complex injury to the femoral artery

B. Medial and lateral incisions are made in both the profunda femoris and superficial femoral arteries. Suturing these sides together produces a larger opening, which can, at times, be primarily sutured to the distal common femoral artery

C. The artery may also be reconstructed using an interposition graft, here depicted with Dacron

D. On occasion, a bridge of prosthetic material can be sutured to the proximal superficial femoral artery, with the foreshortened profunda femoris artery sutured end-to-side to a more distal location in the superficial femoral artery

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FIGURE 52 Popliteal Artery Injury Behind the Knee

A. Among the several options to reconstruct this injury, ligation of the two ends of the vessel with simple bypass using the saphenous vein from the other leg preserves the muscles and tendons at the medial side of the knee (pes anserinus). Depending on presence of associated injuries, the bypass saphenous graft may be passed subcutaneously or deep in the normal traverse of the popliteal artery. Care must be taken to assure the graft does not kink when the knee is flexed

B. In some instances, appropriately sized PTFE graft material may be used

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FIGURE 53 Exposure and Repair of Popliteal Artery and Vein Injuries

Opening the entire medial side of the leg from Hunter’s Canal above, to below the area of the popliteal artery arborization exposes the popliteal artery and vein. Through this incision, the medial head of the gastrocnemius muscle is taken down, and the distal tendinous portions of the semitendinosus and semimembranosus muscles are cut. At the conclusion of the operation and vascular construction, the medial fascial disconnections must be repaired

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FIGURE 54 Exposure and Repair of Popliteal and Tibial Artery Injuries

A. Care is taken that the upper portion of this medial incision does not injure the subcutaneous saphenous vein and that it is sufficiently long enough for exposure of the right proximal tibial artery. The lower extent of the incision should be almost half way down the calf

B. The medial head of the gastrocnemius is taken down and the soleus muscle is exposed. The popliteal artery first gives off the anterior tibial artery, which traverses anteriorly through the interosseous membrane. Once precise vascular control is obtained in the area of the injury, reconstruction can be accomplished

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FIGURE 55 Posterior Exposure of Popliteal Artery Injuries

A. On rare occasion, a posterior approach to the popliteal fossa and its vessels may be desired. This approach prevents access to the groin and often reduces the opportunity for saphenous vein salvage

B. Anatomy as seen for posterior approach of popliteal space

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FIGURE 56 Calf Fasciotomy

A. Cross section of the four compartments of the calf

B. The lateral skin incision is made over the fibula, curving anterior as the incision reaches its upper extents to avoid injury to the superficial peroneal nerve, which can cause foot drop

C. The medial incision is made along the mid-calf, being very careful in the upper extent to avoid iatrogenic injury the subcutaneous saphenous vein, which is a major venous outflow for the foot and calf if the deep tibial veins are ligated

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FIGURE 57 Forearm Fasciotomy

A. A simple, single incision, beginning on the radial side of the anticubital fossa and curving downward to the hand on the ulnar surface of the forearm, allows all the forearm compartments to be released, when needed

B. After the skin flap is developed just above the muscle compartments, any bulging muscle bundle is released. The incision is extended to beyond the retinaculum at the wrist. Through this flap, the superficial and deep volar compartments can be released

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FIGURE 58 Venous Bypass

A patient may be placed on bypass circuit using a centrifugal pump to achieve the desired rate of bypass for various reasons. The rate of return is equal to the rate of blood collection. Bypass may be used to isolate an injured liver by draining the inferior vena cava and portal vein. Alternately (not shown), a femoral vein to axillary vein bypass technique can be used for rewarming a hypothermic patient


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