2. • Access & Exposure
• Incision: Long Midline from Xiphoid to
Pubis
• Major Pitfall: Iatrogenic Injury to
Left Liver, Bowel or Bladder
• Options to Avoid Scars:
• Extend Incision
Superiorly/Inferiorly to Enter Virgin
Territory
• Chevron Incision (Bilateral
Subcostal, Double Kocher, Rooftop)
• Mercedes Incision
• Enter Fast & Eviscerate Bowel Early
ACCESS & EXPOSURE
3. • Approach
• Blunt Trauma: Begin with
Empirical Packing
• Penetrating Trauma: Begin by
Directly Attacking the
Bleeding
• *Some Recommend
Empiric Packing in All
Trauma Cases
TEMPORARY BLEEDING CONTROL
4. • Packing
• Pack Early – Relies on Ability to Form Clot
• Technique:
• “From Within” – Packed into a Cavity Applying Outward Pressure
• “From Without” – Create a Sandwich to Reapproximate
Disrupted Tissue Planes
• Empiric Packing Sites:
• Right Side – Over/Under Liver & Along the Right Gutter
• Left Side – Over/Medial to Spleen & Along the Left Gutter
• Pelvis
5. • Rapid Supraceliac Control (If Exsanguinating)
• Approach:
• Divide Gastrohepatic Ligament
• Normally Avascular
• Watch for Replaced Left Hepatic Artery
• Reflect Stomach/Esophagus to the Left to Visualize the Aorta
• May Require Division of the Diaphragmatic Crura
• Bluntly Dissect the Aorta
• Occlude Aorta Using:
• Manual Compress Against Spine
• Aortic Root Compressor/T-Bar
• Aortic Clamp – Consider Umbilical Tape to Hold Up
• Clamp Distal Thoracic Aorta Through the Abdomen
• Thick Fibrous Attachments as Abdominal Aorta Passes Thorough Diaphragm
• Other Possible Options:
• Thoracotomy with Thoracic Aortic Control
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) –
Controversial
6. EXPLORATION
• Once Bleeding Temporarily Controlled
• Order of Exploration:
• 1. Inframesocolic
• 2. Supramesocolic
• 3. Lesser Sac
• 4. Retroperitoneum
• *Some Report Different Orders of Exploration – Exact
Order is Not as Important as Making Sure to Preform it
the Same Way Every Time & to Not Miss Any Injuries
7. INFRAMESOCOLIC EXPLORATION
• Lift Transverse Colon Cranially
• Run Bowel from Ligament of Treitz to Rectum
• Transverse Colon & Hepatic/Splenic Flexures are
Notorious for Missed Injury
• Inspect Bladder & Pelvis
8. SUPRAMESOCOLIC EXPLORATION
• Pull Transverse Colon Caudally
• Inspect from Right-to-Left
• Palpate Liver, Gallbladder & Right Kidney
• Then Stomach & Duodenum
• Finally, Palpate Spleen & Left Kidney
9. LESSER SAC EXPLORATION
• Bluntly Dissect Through the Greater Omentum (Left Side
Less Vascular)
• Inspect Posterior Stomach & Pancreas
10. RETROPERITONEUM EXPLORATION
• Keep Retroperitoneal Exploration Targeted & Limited
• Clinical Suspicion Based on Missile Trajectory or Presence
of Hematoma
• Maneuvers:
• Mattox
• Cephalad Transverse Mesocolon Reflection
• Kocher
• Cattell-Braasch
• *Understand that There is Significant Overlap with the
Maneuvers & They Should be Tailored to the Individual
Patient
13. MATTOX MANEUVER
• “Left-Sided Medial Visceral Rotation”
• Procedure:
• Mobilize Descending Colon at White Line of Toldt
• Extend Incision Lateral Around the Spleen
• Using Hand Sweep from Below-Up and Medial
• Dissection Plane Directly on the Posterior Abdominal Wall
• Rotate All Structures to the Midline
• Visualize:
• Entire Abdominal Aorta
• Proximal Celiac Axis & SMA
• Left Renal Artery
• Limits IVC Exposure
• Risk: Splenic Injury or Avulsion of Left Descending Lumbar Vein off Renal Vein
14.
15. • Procedure:
• Incise Posterolateral
Peritoneal Attachments of
Duodenum
• Place Hand Behind
Duodenum/Pancreatic Head
and Retract Medially
• Visualize:
• Duodenum (D1, D2, Proximal
D3) & Pancreas
• Suprarenal IVC
• Right Renal Hilum
• Risk: Right Gonadal Vein Injury
KOCHER MANEUVER
16. • Inframesocolic Division
• Used in Vascular Surgery as the Preferred Operative Approach for a Transperitoneal
Open AAA Repair
• Procedure:
• Reflect Transverse Mesocolon Cephalad
• Eviscerate Small Bowel to Right
• Incise Retroperitoneum Along Midline
• From Ligament of Treitz, Left of Aorta
• Extend Caudally to the Right of the Aorta
• Visualize:
• Inframesocolic Aorta
• More Targeted/Limited Than Mattox if Supramesocolic Access is
Unnecessary
• Pitfalls:
• IMV Injury with Initial Cut
• IMA/Sigmoid Mesentery Injury
17. DECISION (DEFINITIVE REPAIR VS.
DAMAGE CONTROL)
• Damage Control Definition
• Definition: Surgery to Stabilize with Delayed Definitive
Repair
• Goals:
• Arrest Hemorrhage
• Limit Contamination
• Maintain Blood Flow
• Temporary Abdominal Closure
• Operative Time Limited to Minimize Further
Hypothermia, Coagulopathy and Acidemia
18. • Damage Control Indications
• Severe Physiologic Insult
• Acidosis (pH < 7.2)
• Base Deficit > 14-15
• Lactate > 5
• Temp < 34-35
• Coagulopathy (Clinical Evidence or INR > 1.5)
• Intraoperative Ventricular Arrhythmia
• High Blood Loss
• Unable to Control Bleeding by Conventional Methods
• Blood Loss > 4 L
• Blood Transfusion > 10 U
19. • Injury Pattern
• 5 Different Injury Patterns
• Difficult to Assess Major Venous Injury
• Massive Hemorrhage from the Pancreatic Head
• Major Liver or Pancreaticoduodenal Injury with Hemodynamic Instability
• Pancreaticoduodenal Devascularization or Massive Disruption with
Involvement of Ampulla or Distal CBD
• Need for Staged Reconstruction
• Need to Reassess Bowel Viability
• Unable to Close Abdominal Wall Without Tension
• Signs of Abdominal Compartment Syndrome While Attempting Closure
26. • Access & Exposure
• Incision: Long Midline from Xiphoid to
Pubis
• Major Pitfall: Iatrogenic Injury to
Left Liver, Bowel or Bladder
• Options to Avoid Scars:
• Extend Incision
Superiorly/Inferiorly to Enter Virgin
Territory
• Chevron Incision (Bilateral
Subcostal, Double Kocher, Rooftop)
• Mercedes Incision
• Enter Fast & Eviscerate Bowel Early
ACCESS & EXPOSURE
27. • Approach
• Blunt Trauma: Begin with
Empirical Packing
• Penetrating Trauma: Begin by
Directly Attacking the
Bleeding
• *Some Recommend
Empiric Packing in All
Trauma Cases
TEMPORARY BLEEDING CONTROL
28. • Packing
• Pack Early – Relies on Ability to Form Clot
• Technique:
• “From Within” – Packed into a Cavity Applying Outward Pressure
• “From Without” – Create a Sandwich to Reapproximate
Disrupted Tissue Planes
• Empiric Packing Sites:
• Right Side – Over/Under Liver & Along the Right Gutter
• Left Side – Over/Medial to Spleen & Along the Left Gutter
• Pelvis
29. • Rapid Supraceliac Control (If Exsanguinating)
• Approach:
• Divide Gastrohepatic Ligament
• Normally Avascular
• Watch for Replaced Left Hepatic Artery
• Reflect Stomach/Esophagus to the Left to Visualize the Aorta
• May Require Division of the Diaphragmatic Crura
• Bluntly Dissect the Aorta
• Occlude Aorta Using:
• Manual Compress Against Spine
• Aortic Root Compressor/T-Bar
• Aortic Clamp – Consider Umbilical Tape to Hold Up
• Clamp Distal Thoracic Aorta Through the Abdomen
• Thick Fibrous Attachments as Abdominal Aorta Passes Thorough Diaphragm
• Other Possible Options:
• Thoracotomy with Thoracic Aortic Control
• Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) –
Controversial
30. EXPLORATION
• Once Bleeding Temporarily Controlled
• Order of Exploration:
• 1. Inframesocolic
• 2. Supramesocolic
• 3. Lesser Sac
• 4. Retroperitoneum
• *Some Report Different Orders of Exploration – Exact
Order is Not as Important as Making Sure to Preform it
the Same Way Every Time & to Not Miss Any Injuries
31. INFRAMESOCOLIC EXPLORATION
• Lift Transverse Colon Cranially
• Run Bowel from Ligament of Treitz to Rectum
• Transverse Colon & Hepatic/Splenic Flexures are
Notorious for Missed Injury
• Inspect Bladder & Pelvis
32. SUPRAMESOCOLIC EXPLORATION
• Pull Transverse Colon Caudally
• Inspect from Right-to-Left
• Palpate Liver, Gallbladder & Right Kidney
• Then Stomach & Duodenum
• Finally, Palpate Spleen & Left Kidney
33. LESSER SAC EXPLORATION
• Bluntly Dissect Through the Greater Omentum (Left Side
Less Vascular)
• Inspect Posterior Stomach & Pancreas
34. RETROPERITONEUM EXPLORATION
• Keep Retroperitoneal Exploration Targeted & Limited
• Clinical Suspicion Based on Missile Trajectory or Presence
of Hematoma
• Maneuvers:
• Mattox
• Cephalad Transverse Mesocolon Reflection
• Kocher
• Cattell-Braasch
• *Understand that There is Significant Overlap with the
Maneuvers & They Should be Tailored to the Individual
Patient
37. MATTOX MANEUVER
• Mobilizes the splenic flexure of the colon inferio-medially
and then allows mobilization of the kidney, spleen and
pancreas superior- medially.
• Completely exposes the anterior and lateral aspect of the
aorta, gives direct access to the celiac trunk, superior and
inferior mesenteric arteries
38. MODIFIED MATTOX MANEUVER
• Modified mattox maneuver is performed by allowing the
kidney to remain in Gerota’s fascia and selecting a dissection
plane that includes the spleen and the pancreas. These
organs are then rotated superiorly and medially.
• This approach give excellent exposure of the celiac trunk,
and the superior mesenteric artery. It also gives ready
access to the left renal pedicle vessels.
39. MODIFIED MATTOX MANEUVER
Mobilization of the left colon
along Toldt’s line.
Reflection begins at the distal
descending colon and extending
the incision past the splenic
flexure, around the posterior
aspect of the spleen, behind the
gastric fundus, and ending at the
oesophagus.
40. MODIFIED MATTOX MANEUVER
The spleen and pancreas are also
mobilized.
With reflection of the spleen,
pancreas, and colon anteriorly toward
the midline, the anterior aspect of
the aorta is exposed along with the
origins of the left renal, superior
mesenteric, and celiac arteries.
The aortic hiatus (left crus) may
need to be incised to provide
additional cephalad exposure
41.
42. NB;
If access to the
posterior aspect
of the aorta is
required, the left
kidney is
mobilized outside
Gerota’s fascia,
along with the
other viscera.
43. PITFALLS OF MATTOX MANUEVER
• Splenic injury
• Avulsion of Left descending lumbar vein (comes off L renal
vein)
44. Involves incision of the ligament
of Treitz and mobilization of the
fourth portion of the duodenum
superiorly and to the right
The left renal vein serves as a
reference to identify the superior
extent of dissection.
INFRARENAL AORTIC EXPOSURE
46. Identify duodenum
Incise posterior
peritoneum immediate
lateral
Reflect the duodenum and
pancreatic head from
retroperitoneum
Allows access to infrahepatic
IVC, distal CBD, duodenum,
pancreatic head, right renal
hilum
KOCHER MANEUVER
47.
48. EXTENDED KOCHER MANEUVER
Carry the classic Kocher
incision caudally along white
line of Toldt
Access to entire
infrahepatic IVC, right
kidney/R hilum, right iliac
vessels
49.
50. Extended Kocher+ incise line
of fusion of small bowel
mesentary to posterior
peritoneum
Swing small bowel and right
colon out of abdomen
CATTELL- BRAASCH MANUEVER
(SUPER- EXTENDED KOCHER)
51. Exposes entire inframesocolic
retroperitoneum, infrarenal
aorta, IVC, L renal hila, L iliac
vessels, superior mesenteric
vessels.
CATTELL-BRAASCH
52. The right colon, duodenum,
and head of the pancreas are
mobilized to expose the vena
cava, the iliac veins, and the
right renal artery and vein.
The renal artery is exposed
by retracting the vein either
cephalic or caudal.
CATTELL-BRAASCH
53.
54. Control of vena cava.
Pressure using digital
compression or sponge
sticks should be sufficient to
control most venous
injuries and avoids
circumferential dissection.
