Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIX: Wounds of the Abdomen

Treatment

United States Department of Defense

Exploration

Before the operation begins, the surgeon should be certain that illumination is as good as it can be. The surgeon must understand the capabilities of the assistant. Mutual understanding between the surgeon and the assistant must be reached before the operation begins. This understanding must consider the ability of the assistant to obtain hemostasis as well as the assistant's understanding of anatomy, knowledge of general surgical principles, and operative exposure. The surgeon should understand exactly how much (or how little) suction will be available. The surgeon should consider all of these factors when planning the operation.

The incision should be a long midline incision, generally from the xiphoid to the pubic symphysis.

Hemostasis

The surgeon and the rest of the operative team must have a plan before the peritoneal cavity is entered. If there is a great deal of free blood, it is best to use several large laparotomy pads to evacuate the blood. Suction with irrigation is more effective after the bulk of free blood has been removed. The surgeon must quickly decide which area of the abdomen demands first attention. Generally, the amount of hemorrhage will be the determining, factor. Direct pressure on individual vessels such as the splenic artery, the great vessels, or the descending thoracic aorta through a limited thoracotomy might be necessary at this time. The first assistant's experience and knowledge of anatomy are critical in the plan for these actions.

Exposure

It is simpler to eviscerate the entire small bowel in complicated cases. The ligaments of the liver can be divided to obtain further exposure in the right upper quadrant. Access to the thoracic cavity should be obtained by extending the midline abdominal incision into a median sternotomy.

The surgeon must have a systematic plan to explore the abdomen. This is similar to an aviator's pre-flight checklist and serves the same purpose to insure that no important step is missed. The excitement and distractions of combat surgery dictate that no laparotomy is concluded until the entire abdominal cavity has been explored.

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Operational Medicine 2001

Health Care in Military Settings

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