Atlas of Surgical Techniques in Trauma

Atlas of Surgical Techniques in Trauma
Atlas of Surgical Techniques

in Trauma
Edited by
Demetrios Demetriades MD PhD FACS
Professor of Surgery at the University of Southern California, and Director of Trauma, Emergency Surgery and Surgical Critical Care at the
Los Angeles County and University of Southern California Medical Center, Los Angeles, California, USA
Kenji Inaba MD MSc FACS FRCSC

Associate Professor of Surgery and Emergency Medicine and Program Director for the Surgical Critical Care Fellowship and Surgery Residency at the
University of Southern California, Los Angeles, California, USA
George Velmahos MD PhD FACS

John F. Burke Professor of Surgery at Harvard Medical School, and Chief of Trauma, Emergency Surgery and Surgical Critical Care at
Massachusetts General Hospital, Boston, Massachusetts, USA
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Library of Congress Cataloging in Publication data
Atlas of surgical techniques in trauma / edited by Demetrios
Demetriades, Kenji Inaba, George Velmahos.
p. ; cm.
Includes index.
ISBN 978-1-107-04459-3 (Hardback)
I. Demetriades, Demetrios, 1951– , editor. II. Inaba, Kenji, editor.
III. Velmahos, George C., editor.
[DNLM: 1. Wounds and Injuries–surgery–Atlases. WO 517]
RD93
617.044–dc23 2014023642
ISBN 978-1-107-04459-3 Hardback
Cambridge University Press has no responsibility for the persistence
or accuracy of URLs for external or third-party internet websites
referred to in this publication, and does not guarantee that any
content on such websites is, or will remain, accurate or appropriate.
.........................................................................................
Every effort has been made in preparing this book to provide

accurate and up-to-date information which is in accord with accepted
standards and practice at the time of publication. Although case
histories are drawn from actual cases, every effort has been made to
disguise the identities of the individuals involved. Nevertheless, the
authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least
because clinical standards are constantly changing through research
and regulation. The authors, editors and publishers therefore disclaim
all liability for direct or consequential damages resulting from the
use of material contained in this book. Readers are strongly advised to
pay careful attention to information provided by the manufacturer
of any drugs or equipment that they plan to use.
To my parents, my wife Elizabeth, my daughters Alexis and
Stefanie, and my son Nicky.
D. Demetriades
To my parents, wife Susie and son Koji, thank you for all of your support.
K. Inaba
To those who inspired me and those who allowed me to become a trauma

surgeon: my teachers and my parents.
G. Velmahos
Contents
List of contributors ix
Preface xi
Acknowledgments xii
Introduction – Kenneth L. Mattox xiii
Section 1 – Operating Room General Conduct 11. Vertebral artery injuries 88

Demetrios Demetriades and Nicholas Nash
1. Trauma operating room 1
12. Trachea and larynx 94
Kenji Inaba and Lisa L. Schlitzkus
Elizabeth R. Benjamin and Kenji Inaba
13. Cervical esophagus 101
Section 2 – Resuscitative Procedures in the Elizabeth R. Benjamin and Kenji Inaba
Emergency Room
2. Cricothyrotomy 5 Section 5 – Chest
Peep Talving and Rondi Gelbard
14. General principles of chest trauma
3. Thoracostomy tube insertion 12 operations 107
Demetrios Demetriades and Lisa L. Schlitzkus Demetrios Demetriades and Rondi Gelbard
4. Emergency room resuscitative thoracotomy 18 15. Cardiac injuries 115
Demetrios Demetriades and Scott Zakaluzny Demetrios Demetriades and Scott Zakaluzny
16. Thoracic vessels 126
Section 3 – Head Demetrios Demetriades and Stephen Varga
5. Insertion of intracranial pressure monitoring 17. Lung injuries 140

catheter 29 Demetrios Demetriades and
Howard Belzberg and Matthew D. Tadlock Jennifer Smith
6. Evacuation of acute epidural and subdural 18. Thoracic esophagus 150

hematomas 35 Daniel Oh and Jennifer Smith
Gabriel Zada and Kazuhide Matsushima 19. Diaphragm injury 162
Lydia Lam and Matthew D. Tadlock
Section 4 – Neck
7. Neck operations for trauma: general principles 47 Section 6 – Abdomen
Emilie Joos and Kenji Inaba
20. General principles of abdominal operations
8. Carotid artery and internal jugular vein injuries 53 for trauma 165
Edward Kwon, Daniel J. Grabo, and George Velmahos Heidi L. Frankel and Lisa L. Schlitzkus
9. Subclavian vessels 69 21. Damage control surgery 172
Demetrios Demetriades and Jennifer Smith Mark Kaplan and Demetrios Demetriades
10. Axillary vessels 83 22. Gastrointestinal tract 180
Demetrios Demetriades and Emilie Joos Kenji Inaba and Lisa L. Schlitzkus
vii
Contents
23. Duodenum 189 33. Upper extremity fasciotomies 288

Edward Kwon and Demetrios Demetriades Jennifer Smith and Mark W. Bowyer
24. Liver injuries 198 34. Upper extremity amputations 294
Kenji Inaba and Kelly Vogt Peep Talving and Scott Zakaluzny
25. Splenic injuries 209
Demetrios Demetriades and Matthew D. Tadlock
Section 9 – Lower Extremities
26. Pancreas 219
Demetrios Demetriades, Emilie Joos, and George Velmahos 35. Femoral artery injuries 303
George Velmahos and Rondi Gelbard
27. Urological trauma 228
Charles Best and Stephen Varga 36. Popliteal artery 307
Peep Talving and Nicholas Nash
28. Abdominal aorta and visceral branches 240
Pedro G. Teixeira and Vincent L. Rowe 37. Lower extremity amputations 314
Peep Talving, Stephen Varga, and Jackson Lee
29. Iliac injuries 257
Demetrios Demetriades and Kelly Vogt 38. Lower extremity fasciotomies 323
Peep Talving, Elizabeth R. Benjamin, and
30. Inferior vena cava 262 Daniel J. Grabo
Lydia Lam and Matthew D. Tadlock
Section 7 – Pelvis Section 10 – Orthopedic Damage

31. Surgical control of pelvic fracture hemorrhage 273 Control
Peep Talving and Matthew D. Tadlock 39. Orthopedic damage control 337
Eric Pagenkopf, Daniel J. Grabo, and Peter Hammer
Section 8 – Upper Extremities

32. Brachial artery injury 281
Peep Talving and Elizabeth R. Benjamin Index 345
viii
Contributors
Howard Belzberg Peter Hammer

Professor of Surgery, Division of Trauma, Assistant Professor of Clinical Surgery,
Emergency Surgery and Surgical Critical Care, Division of Trauma, Emergency Surgery and
University of Southern California, Los Angeles, CA, USA Surgical Critical Care, University of Southern California,
Los Angeles, CA; Commander, Medical Corps, United States
Elizabeth R. Benjamin Navy, USA
Assistant Professor of Clinical Surgery, Division of Trauma,
Emergency Surgery and Surgical Critical Care, Kenji Inaba
University of Southern California, Los Angeles, CA, USA Associate Professor, Surgery and Emergency Medicine and
Program Director, Surgical Critical Care Fellowship and
Charles Best Surgery Residency, University of Southern California,
Assistant Professor of Clinical Urology and Surgery and Chief Los Angeles, CA, USA
of Service, Department of Urology, Los Angeles County and
University of Southern California Medical Center, Emilie Joos
Los Angeles, CA, USA Clinical Instructor, Division of Trauma, Emergency Surgery
and Surgical Critical Care, University of Southern California,
Mark W. Bowyer Los Angeles, CA, USA
Chief, Division of Trauma and Combat Surgery and Ben
Eisman Professor of Surgery, The Norman M. Rich Mark Kaplan
Department of Surgery, Uniformed Services University, Professor of Surgery, Director of Trauma and Surgical
Bethesda, MD; Colonel (retired), United States Air Force, USA Critical Care and Director of Acute Care Surgery,
Albert Einstein Medical Center, Philadelphia, PA, USA
Demetrios Demetriades
Professor of Surgery, University of Southern California; Edward Kwon
Director of Trauma, Emergency Surgery and Surgical Critical Assistant Professor of Clinical Surgery, Division of Trauma,
Care, Los Angeles County and University of Southern Emergency Surgery and Surgical Critical Care,
California Medical Center, Los Angeles, CA, USA University of Southern California, Los Angeles, CA, USA
Heidi L. Frankel Lydia Lam
Professor of Surgery, Division of Trauma, Assistant Professor of Surgery, Division of Trauma,
Emergency Surgery and Surgical Critical Care, Emergency Surgery and Surgical Critical Care,
University of Southern California, Los Angeles, CA, USA University of Southern California, Los Angeles, CA, USA
Rondi Gelbard Jackson Lee
Clinical Instructor in Surgery, Division of Trauma, Associate Professor of Clinical Medicine,
Emergency Surgery and Surgical Critical Care, Department of Orthopedics, Keck School of Medicine,
University of Southern California, Los Angeles, CA, USA Los Angeles, CA, USA
Daniel J. Grabo Kazuhide Matsushima
Assistant Professor of Clinical Surgery, Division of Trauma, Surgical Critical Care Fellow, Division of Trauma,
University of Southern California, Los Angeles, CA; University of Southern California, Los Angeles,
Lieutenant Commander, United States Navy, USA CA, USA
ix
List of contributors
Nicholas Nash Peep Talving

Clinical Instructor, Division of Trauma, Assistant Professor of Surgery, Division of Trauma,
University of Southern California, Los Angeles, CA, USA University of Southern California, Los Angeles, CA, USA
Daniel Oh Pedro G. Teixeira
Assistant Professor of Surgery, Department of Thoracic Surgical Critical Care Fellow, Division of Trauma,
Surgery, University of Southern California, Emergency Surgery and Surgical Critical Care,
Los Angeles, CA, USA University of Southern California, Los Angeles, CA, USA
Eric Pagenkopf Stephen Varga
Assistant Professor in Orthopedics and Director, Clinical Instructor, Division of Trauma,
Navy Trauma Training Center, Los Angeles County and Emergency Surgery and Surgical Critical Care,
University of Southern California Medical Center, University of Southern California, Los Angeles, CA;
Los Angeles, CA; Captain (Retired), United States Navy, USA Major, United States Air Force, USA
Vincent L. Rowe George Velmahos
Professor of Surgery, Division of Vascular Surgery, John F. Burke Professor of Surgery, Harvard Medical School;
University of Southern California, Los Angeles, CA, USA Chief of Trauma, Emergency Surgery and Surgical Critical
Care, Massachusetts General Hospital, Boston,
Lisa L. Schlitzkus Massachusetts, USA
Surgical Critical Care Fellow, Division of Trauma,
Emergency Surgery and Surgical Critical Care, Kelly Vogt
University of Southern California, Los Angeles, CA, USA Clinical Instructor in Surgery, Division of Trauma,
Emergency Surgery and Surgical Critical Care,
Jennifer Smith University of Southern California, Los Angeles, CA, USA
Assistant Professor of Surgery, Division of Trauma,
Emergency Surgery and Surgical Critical Care, Gabriel Zada
University of Southern California, Los Angeles, CA, USA Assistant Professor of Clinical Neurosurgery,
University of Southern California, Los Angeles, CA, USA
Matthew D. Tadlock
Clinical Instructor in Surgery, Division of Trauma, Emergency Scott Zakaluzny
Surgery and Surgical Critical Care, University of Southern Clinical Instructor in Surgery, Division of Trauma,
California, Los Angeles, CA; Lieutenant Commander, Medical Emergency Surgery and Surgical Critical Care,
Corps, United States Navy, USA University of Southern California, Los Angeles, CA, USA
x
Preface
The aim of this Atlas of Surgical Techniques in Trauma is to What makes this atlas unique is the use of images obtained
provide a valuable companion in the operating room to the from fresh, perfused, and ventilated human cadavers. Many
surgeons who provide care to the injured. It is designed to be a hundreds of hours were spent in the USC Fresh Tissue Dissec-
rapid, highly visual summary of the critical anatomy, proced- tion Lab for this project. The critical aspects of each surgical
ural sequencing, and pitfalls associated with these procedures, exposure and procedure are clearly demonstrated in these
ideal for trainees as well as for those in practice, as a rapid high-fidelity models, allowing the reader to rapidly understand
review of both common and uncommonly performed proced- the technical key points, which are often difficult to convey
ures prior to proceeding to the operating room. using words alone. The extensive real-world clinical experience
The atlas is organized into chapters and sections according of the editors and senior authors in managing complex injuries
to anatomical areas. It includes more than 630 high-quality at large trauma centers, combined with these high-quality
photographs and illustrations and is written in a reader- operative photos and technical illustrations make this atlas an
friendly format, which includes practical surgical anatomy, important tool in the armamentarium of the practicing
general principles, exposure, definitive management, and tech- surgeon.
nical tips and pitfalls. It guides the surgeon, step by step,
through the entire procedure, from incision to closure. Demetrios Demetriades, Kenji Inaba, and George Velmahos
xi
Acknowledgments
The editors and authors greatly acknowledge the major contri- with the anatomical dissections and photos in the Fresh Tissue
butions of Alexis Demetriades, Scientific Illustrator; Michael Dissection Lab.
Minneti and Andrew Cervantes for coordinating and helping
xii
Introduction
A contemporary focused Atlas of surgical techniques in standardized material that is easily remembered and recalled
trauma has been a much needed adjunct to the didactic text- because of its unique presentation.
books, conferences and symposia, and other instructional Finally, any user of this atlas must grant me some moments
material available in the field of acute care surgery and trauma. of historic reflection and confession. Although I spent much of
Although adjunctive descriptors have been part of many my medical school days trying to impress by taking detailed
monographs and formal textbooks on the subject of trauma lecture notes, subscribing to and “fake reading” the New Eng-
techniques, this unique atlas will significantly aid all who care land Journal of Medicine, buying the recommended detailed
for injured patients. long textbooks on the subject de jour, and trying to remain
This book is Unique in a number of aspects. It is a work awake in my usual seat in the third row of the lecture room,
product of a single group of physicians who are, or have been my medical school and residency life suddenly became pro-
in the past, in the faculty of a single institution with a singular ductively alive when I discovered the Surgical Technique atlases
approach to most operative techniques in this field. The sur- in the library. I avidly consumed these books. They were
geons in this institution, Los Angeles County & Southern always huge and could not easily be carried around, but I
California Medical Center in Los Angeles, also have integrated managed to do just that. Becoming a surgical resident, I
their educational material using human cadaver material in a purchased and still own the (“big names”) popular surgical
standardized and innovative approach. The cadaver anatomic technique atlases of the day (1967–1971). As the big names
material is correlated in a standardized manner, facilitating an stopped producing new atlases with their wonderful artwork,
appreciation of the dynamics of exposure, control, and man- they became historic memories on the shelves of my office. For
agement. Anatomic drawings benefit the detailed learner decades, I could find no quality renewals or replacements.
during course instruction as well as the surgeon seeking Now, with this well-organized, standardized, focused Atlas of
rapid review at the time of an urgent operation. Once the Surgical Techniques in Trauma, those experiences no longer
reader recognizes the standardized approach to teaching, pro- will be mere memories. Thank you, Demetrios and your won-
gressing through any chapter or subject in the atlas is quick derful team of artists, pathologists, and surgeons for this beau-
and easy. This atlas material is also very amenable to small tiful and innovative atlas and for the incredible learning
portable electronic devices, allowing a ready source for anat- experience it will give all caring for injured patients.
omy correlations, exposure recommendations, and reconstruc-
tion details – anywhere and at any time. Kenneth L. Mattox, MD, FACS
This Atlas is Not simply a collection of drawings. It is an Distinguished Service Professor Baylor College of Medicine
Atlas textbook of techniques. It is a philosophy of surgical Chief of Staff/Chief of Surgery
approaches – “a recipe.” It is the type of book that would/ Ben Taub General Hospital
should have been shared with the learner by his/her mentor Houston
very early on. It is like bedtime reading – to be enthusiastically
rendered to an enthusiastic recipient. It is the type of
xiii
Section 1 Operating Room General Conduct
Trauma operating room

Chapter
1 Kenji Inaba and Lisa L. Schlitzkus
Operating room other ORs, blood bank, and laboratory should be

A large operating room (OR) situated near the emergency in place.
department, elevators, and ICU should be designated All rooms should have ample overhead lighting as well as
as the Trauma OR to facilitate the logistics of patient access to portable headlamps.
flow and minimize transport. The room should be Multiple monitors to display imaging, vital signs, and
securable for high profile patients. laboratory data such as thromboelastometry should be in place.
A contingency plan for multiple simultaneous Hybrid operating and interventional radiology suites are
operations should be in place with the operating ideal. Both the surgical and radiology teams should be
rooms in sufficient proximity to allow nursing and familiar with operating in the hybrid room.
anesthesia cross-coverage and facilitate supervision A dedicated family waiting room should be identified, and
of the surgical teams. Direct lines of communication all family should be directed to this area for the
between the OR and the resuscitation area, ICU, postoperative discussion.
Atlas of Surgical Techniques in Trauma, ed. Demetrios Demetriades, Kenji Inaba, and George Velmahos. Published by Cambridge University
Press. © Cambridge University Press 2015.
1
Section 1: Operating Room General Conduct
Fig. 1.1. Hybrid operating room setup.
Setup and equipment standard suture tree including sternal closure wires,
vascular sutures, and liver sutures
Nursing staff should be regularly in-serviced about the
trauma room setup, supplies, and common practices such adult and pediatric code cart
as massive transfusion to minimize problems due to service high volume suction canister and device
line cross-coverage. tourniquets
While all attempts should be made to count instruments endotracheal tube occluders
and ensure a correct final count, this may be postponed in rigid sigmoidoscope, bronchoscope, gastroscope
life-threatening or damage control situations. Radio- portable fluoroscopy and personnel shielding devices
frequency ID device embedded laparotomy sponges are a should be immediately available for use in the OR
useful adjunct to these emergency situations. an electrothermal bipolar vessel sealing system device
(LigaSure device) is desirable.
The following should be readily available:
instrument trays including laparotomy, sternotomy with Warming
pneumatic sternal saw, thoracotomy, emergency airway, Due to the large surface area exposed, trauma patients are
amputation, and peripheral vascular susceptible to hypothermia.
a wide selection of vascular shunts, catheters, vascular The room should not be cold.
conduits, chest tubes, drains, staplers, local hemostatic Forced air blankets should be used.
agents, advanced thermal cutting devices, and temporary Warmed intravenous fluids should be available at all times.
abdominal closure supplies All irrigation fluids should be warmed.
2
Chapter 1. Trauma operating room
Blood
A type and screen should be sent immediately to the
laboratory upon patient arrival to the emergency
department.
Emergency release products (uncross-matched O or O+
packed red blood cells as well as thawed AB or low titer
A plasma) should be readily available in the emergency
department and in the operating room.
A rapid transfusion device should be available.
Fig. 1.2. Emergency release blood products

stored in a refrigerator in the emergency
department or operating room available for
immediate use. Can contain uncrossed matched
O+ or O packed red blood cells and AB or low
titer A plasma.
3
Section 2 Resuscitative Procedures in the Emergency Room
Cricothyrotomy
Chapter
2 Peep Talving and Rondi Gelbard
Surgical anatomy The vocal cords are attached to the internal

The cricothyroid membrane lies between the cricoid anterior surface of the thyroid cartilage, about 1 cm
and thyroid cartilage and is bordered laterally by the from the upper border of the cricothyroid
cricothyroid muscles. In adults it is about 1 cm in membrane.
height and about 2–3 cm wide, including the area Localizing the cricothyroid membrane rapidly can be
covered by the two cricothyroid muscles. The actual critical in managing the difficult airway. If soft tissue
membrane between the two muscles is approximately trauma or obesity prevents clear identification of the
1 cm wide. thyroid and cricoid cartilage, with the neck in neutral
The cricoid cartilage is the only complete ring in the position, place the tip of the small finger of the
trachea. It serves as a stent supporting the airway and is an extended hand in the suprasternal notch. The tip of the
important attachment point for muscles and index finger will touch the cricothyroid membrane in
ligaments. the midline.
(a) (b)
Thyroid cartilage
Thyroid cartilage Cricothyroid muscles
Cricothyroid membrane Cricoid cartilage
Cricothyroid muscle
Cricoid Trachea
Cricothyroid membrane
Fig. 2.1(a), (b). Anatomy of the cricothyroid space. The cricothyroid space includes the inferior border of the thyroid cartilage and the superior rim of the cricoid
arch that are connected by the cricothyroid membrane, and are partially covered by the cricothyroid muscles.
5
Section 2: Resuscitative Procedures in the ER
(a) insufflation should be considered. For patients with suspected

tracheal transection, this procedure should also be avoided.
HEAD
There is no evidence to support routine conversion of a
cricothyrotomy to a formal tracheostomy.
Special instruments
The open cricothyrotomy instrument set should include
endotracheal and tracheostomy tubes (size 6 French),
Thyroid cartilage
scalpel, tracheal hook, Senn retractors, Kelly clamp,
Cricothyroid space Metzenbaum scissors, and forceps.
Cricoid Suction with an endoluminal suction catheter
attachment.
Alternatively, commercially available percutaneous
Suprasternal notch cricothyrotomy sets can also be used.
End-tidal CO2 detector should be available.
Adequate lighting.
Fig. 2.2(a). Surface anatomy of the cricothyroid space. The cricothyroid
space includes the inferior border of the thyroid cartilage and the superior rim (a)
of the cricoid arch. In adults the cricothyroid membrane is about 1 cm in height
and about 2–3 cm wide.
(b)
HEAD
A B
Suprasternal notch
Fig. 2.3(a). Open cricothyrotomy instrument set should include endotracheal
and tracheostomy tubes, scalpel, tracheal hook (A), Senn retractors (B), Kelly
clamp, Metzenbaum scissors, and forceps.
(b)
Fig. 2.2(b). Photograph demonstrating the four-finger technique for

identifying the cricothyroid membrane. With the palm extended, the tip of the
small finger is placed in the suprasternal notch. The tip of the index finger
touches the cricothyroid membrane in the midline (x).
General principles
Cricothyrotomy is indicated in patients requiring emergent
airway management who cannot be intubated by the oral or
nasal route, and cannot be oxygenated with alternative rescue
techniques such as the Laryngeal mask airway, or Combitube.
Severe maxillofacial trauma, or edema of the glottis are
common conditions requiring cricothyrotomy.
Cricothyrotomy is relatively contraindicated in patients
under 8 years of age, because of the small size of the
cricothyroid membrane and propensity to develop post-
procedure stenosis. In these pediatric patients, needle jet Fig. 2.3(b). Commercial percutaneous cricothyrotomy set.
6
Chapter 2. Cricothyrotomy
Patient positioning Technique

Supine, with the neck in neutral position if the cervical
spine has not been cleared. If cleared, the neck should be
Percutaneous cricothyrotomy
extended to facilitate this procedure. Begin with a 5 mm long vertical skin incision. In patients
with a short and thick neck it may be difficult to palpate the
cricothyroid membrane. The “four-fingers technique” as
described above can help identify the cricothyroid space.
This will localize the area where the initial skin incision
HEAD should be made. Once the skin incision is made, re-
examine the anatomy. Once the skin is breached, the
underlying structures will become easier to localize. The
skin incision must be sufficiently large to allow entry of the
tube. Insufficient incision length is a common pitfall.
Stabilize the thyroid cartilage between the thumb and the
middle finger of the non-dominant hand to facilitate
palpation of the anatomical landmarks and immobilize the
airway during the procedure.
With the dominant hand, insert the needle into the
cricothyroid membrane directed caudally at a 45o angle. If
time is available, the needle can be attached to a syringe
that is filled with normal saline to visualize entry into the
airway.
As the needle is advanced, apply negative pressure to the
syringe.
Advance the needle until it traverses the membrane and
enters the trachea, signaled by a distinct pop and aspiration
of air. If saline was placed in the syringe, bubbles will
be seen.
Remove the needle and syringe, leaving the catheter in
place. Advance the guide wire through the catheter. The
catheter can then be removed.
Place the dilator into the airway catheter, and insert both
the dilator and catheter together over the guidewire,
ensuring that guidewire is not advancing with the cannula/
dilator complex.
Remove both the dilator and the guidewire once the airway
tube is secured in the trachea.
Fig. 2.4. The neck is in neutral or slightly extended position. The trachea is Secure the tube in place.
immobilized between the thumb and middle finger of the non-dominant hand
to prevent lateral movement of the trachea during the procedure. The index
finger may be used to palpate the cricothyroid space.
7
(a) (b)
Suprasternal notch
HEAD
HEAD
(c) (d)
HEAD
(e) (f)
HEAD
HEAD
Fig. 2.5(a)–(f). Technique of percutaneous cricothyrotomy. The finder needle attached to a saline-filled syringe is inserted into the cricothyroid
membrane, directed caudally at a 45o angle to avoid puncturing the posterior wall of the trachea. The needle and syringe are removed, leaving the small
catheter in place. The guidewire is advanced through the catheter, and the catheter is removed once the guidewire is in place (b) and (c). The assembled dilator
and airway catheter are inserted together, over the guidewire, into the trachea (d); the guidewire and dilator are removed once the airway tube has been secured (e);
airway cannula in place (f).
8
Open cricothyrotomy exposing the cricothyroid membrane. Senn retractors can

be utilized for exposure if an assistant is available.
With the non-dominant hand, stabilize the thyroid
cartilage between the thumb and index finger. Make a horizontal stab incision through the cricothyroid
membrane.
With the dominant hand, make a 3 cm midline vertical
incision over the cricothyroid membrane. A transverse If practical, perform the incision in the lower half of the
cricothyroid membrane, along the superior border of the
incision is an acceptable option, but a vertical incision is
cricoid cartilage, in order to avoid injuring the cricothyroid
preferred because there is a decreased risk of bleeding from
artery which courses through the superior half of the
the anterior jugular veins and the incision is more versatile
cricothyroid membrane.
as it can easily be extended.
Insert the tracheal hook at the superior end of the
Utilize the thumb and index finger of the non-dominant
cricothyroid incision and retract the thyroid cartilage
hand that is stabilizing the cartilage to retract the skin,
cephalad.
(a) (b)
HEAD
HEAD
Fig. 2.6(a). Technique of open cricothyrotomy. The trachea is immobilized Fig. 2.6(b). A horizontal incision is made through the cricothyroid membrane
with the non-dominant hand. A 3-cm midline vertical skin incision is performed to enter the trachea. This incision should be made in the lower half of the
over the cricothyroid membrane. cricothyroid membrane, along the superior border of the cricoid cartilage, in
order to avoid injuring the cricothyroid artery.
(c) (d)
Chest HEAD
HEAD
Fig. 2.6(c), (d). Following entry into the trachea, a tracheal hook is placed at the edge of the thyroid cartilage (arrow), and firm retraction is applied upward and
toward the head (c). Alternatively, the tracheal hook may be placed inferiorly, on the cricoid ring with traction toward the patient’s chest (d). The skin incision is
retracted laterally, with Senn retractors.
9
Section 2: Resuscitative Procedures in the ER
With the dominant hand, insert the cricothyrotomy tube (e)

into the trachea.
Having the obturator in place will aid in this process. Once
seated in the airway, the obturator is removed and the
inner cannula can be inserted.
Inflate the balloon with 5–10 mL of air, and confirm
placement with observation of chest rise, auscultation, and
assessment of end-tidal CO2.
Secure the tube in place and clear the airway of blood and
secretions by suctioning through the cricothyrotomy tube.
HEAD
(f)
HEAD
Fig. 2.6(e), (f). Insertion of the airway cannula in a caudal direction. Airway
access is obtained, and appropriate location of the airway cannula is ensured
with end-tidal CO2.
10
Tips and pitfalls cartilage with a tracheal hook and direct visualization of
tube entry into the airway.
A cricothyrotomy may be a difficult procedure in patients
The thyrohyoid space may be mistaken for the cricothyroid
with a short and thick neck.
space and the tube is inserted too high. In order to avoid
In obese patients, it is often difficult to palpate the this complication, both the thyroid cartilage and cricoid
cricothyroid space. In these cases, the cricothyroid membrane
ring should be clearly identified.
is usually located four finger breadths above the suprasternal
Posterior tracheal wall perforation is a serious
notch (the “four fingers” trick). Once the skin incision is
complication. Avoid pushing any instruments or the tube
made, the underlying structures become easier to palpate.
in the anteroposterior direction. Instead, follow the
Reduce the risk of bleeding from the anterior jugular veins direction of the trachea.
by performing a vertical skin incision.
Cricothyrotomy can be utilized in adults for prolonged
If the skin incision is too low, the thyroid isthmus is in the airway access with a low incidence of subglottic stenosis.
way and its division may cause bleeding.
The authors do not advocate routine conversion of a
An insufficient skin incision is often the primary cricothyrotomy to a tracheostomy.
obstruction to smooth insertion of the tube into the airway.
In pediatric patients consider using needle jet insufflation
Incorrect placement of the tube into the subcutaneous rather than cricothyrotomy.
tissues can be mitigated by immobilization of the thyroid
11
Thoracostomy tube insertion

Chapter
3 Demetrios Demetriades and Lisa L. Schlitzkus
General principles (a)
Strict antiseptic precautions and personal protective

equipment should be used during the procedure. A single
dose of prophylactic antibiotics with Cefazolin should be
administered before the procedure. There is no need for
further prophylaxis.
Chest tubes can be inserted with an open or percutaneous
dilational technique.
The site of insertion is the same for open or percutaneous
insertion and for hemothorax or pneumothorax at the
fourth or fifth intercostal space, at or above the level of the
nipple in males.
Autotransfusion should be considered in all cases with
large hemothoraces.
(b)
Positioning
The patient should be placed in the supine position with the
arm abducted at 90 degrees and elbow fully extended or flexed
at 90 degrees cephalad. Adduction and internal rotation of the
arm is a suboptimal position and should not be used.
Site of tube insertion

Fourth or fifth intercostal space, mid axillary line. The
external landmark is at, or slightly above, the nipple level in
males and at the inframammary fold in females. Insertion
at this site is optimal due to the relatively thin chest wall
and distance from the diaphragm, which during expiration Fig. 3.1 (a)–(c). The patient should be placed in the supine position with
can easily reach the sixth intercostal space. the arm abducted at 90 degrees and elbow fully extended (a) or flexed
cephalad at 90 degrees. The insertion site should be in the fourth or fifth
intercostal space at the mid axillary line, at or slightly above the nipple level (b).
Adduction and internal rotation of the arm is a suboptimal position and should
not be used (c).
12
Chapter 3. Thoracostomy tube insertion
(c) clamp is released and withdrawn, while the tube is

advanced in a twisting fashion towards the apex and
posteriorly. Make sure that all of the tube fenestrations are
in the pleural cavity. In an adult patient the tube should be
inserted to 8–10 cm. Alternatively, the tube can be inserted
without a clamp into the pleural cavity alongside the index
finger of the non-dominant hand, which is then used to
guide the tube posteriorly towards the apex. If the tube
does not slide in smoothly, the tip may be caught in a
fissure or by lung parenchyma. The tube should be
withdrawn and re-inserted to prevent injury to the lung or
other mediastinal structures.
When the tube is in place, it should be rotated 360 degrees
to prevent inappropriate kinking. If the tube does not
rotate freely, it should be pulled back slightly and
rotated again.
Fig. 3.1 (a)–(c). (cont.)
Open technique
Usual thoracostomy tube sizes for adults are 28–32 Fr;
there is no advantage to using larger tubes. For pediatric
cases, refer to the Broselow tape. Fig. 3.2. Preparation of the chest tube: the tube is grasped with a clamp
After local anesthetic is injected in the skin, soft tissue, and through its distal fenestration. The distal end of the tube (left) is clamped to
along the periosteum, a 1.5–2.0 cm incision is made avoid splashing of blood.
through the skin and subcutaneous fat. The greater the soft
tissue thickness, the longer the skin incision should be. An
inadequate incision can compromise safe and accurate
placement in the obese patient.
A Kelly forceps is used to enter the pleural cavity.
Dissection should be kept close to the upper edge of the rib
to avoid injury to the intercostal vessels. The Kelly forceps
is inserted into the pleural cavity in a controlled manner to HEAD
avoid injury to the intrathoracic organs.
There is no need for subcutaneous tunneling as it is painful
and does not reduce the risk of empyema or air leak.
A finger should be inserted into the pleural cavity, and
swept 360 degrees to evaluate for adhesions and avoid
intrapulmonary placement of the tube.
The tube is grasped with a clamp through its distal
fenestration. The distal end of the tube is clamped to avoid
uncontrolled drainage of blood. The tube is firmly inserted Fig. 3.3. A 1.5–2.0 cm incision is made through the skin and subcutaneous fat,
into the pleural cavity. As soon as it enters the cavity, the in the fourth or fifth intercostal space at the mid axillary line.
13
Section 2: Resuscitative Procedures in the Emergency Room
(a) (b)
Fig. 3.4(a),(b). Kelly forceps are used to enter the pleural cavity just over the top of the rib. Spreading of the subcutaneous fat and tissue occurs as the Kelly clamp is
withdrawn from the pleural cavity.
(a)
Fig. 3.6(a),(b). The tube is grasped with a Kelly clamp through its distal
fenestration and is firmly forced into the pleural cavity.
Fig. 3.5. Digital exploration of the pleural cavity to rule out adhesions.
(c)
(b)
HEAD
Fig. 3.6(c). When the tip of the tube enters the cavity, the clamp is released
and withdrawn, while the tube is advanced in a twisting fashion towards the
Fig. 3.6(a),(b). (cont.) apex and posteriorly.
14
(d) border of the rib to avoid injury to the intercostal vessels,

which are located at the inferior border of the rib. Aim
slightly posterior and towards the apex of the lung. Entry
into the pleural cavity is confirmed by aspiration of blood
or air bubbles.
Insert the guidewire through the needle. Remove the needle
while keeping the guidewire in place. Make a skin incision
over the needle that is slightly larger than the diameter of
the chest tube. Remove needle.
Insert the dilator over the guidewire.
Remove dilator and insert the chest tube (8–10 cm) over
the guidewire.
Remove the guidewire, connect to the collection system,
and secure the tube on the skin.
Obtain chest X-ray.
Fig. 3.6(d). Chest drain in place (in normal-weight adults, no more than 8–10
cm of the drain should be inserted into the chest).
Connect tube to an underwater chest drainage collection

system and apply wall suction at 20 cm H2O.
Secure tube with 0 silk. Encourage the patient to cough
while sitting up, lying on their back and sides in order to
promote blood drainage and lung re-expansion.
If the incision at the insertion site is too long, it should be
closed around the tube with interrupted sutures.
A horizontal mattress suture may be placed around the
tube and left untied to be used for wound closure at the
time of tube removal. The tube is further secured to the
thoracic wall with adhesive tape.
Percutaneous technique
Less painful than the open technique.
After infiltrating the area with local anesthetic, an
introducer needle attached to a syringe with sterile saline is
inserted into the chest cavity. Insert close to the upper Fig. 3.7. A percutaneous chest tube tray.
Fig. 3.8. The percutaneous dilational insertion of chest tube utilizes the Seldinger guidewire technique with progressive dilation.
15
(a) (b) (c)
HEAD
Fig. 3.9. The step-by-step insertion of a percutaneous chest tube by the dilational technique: photograph of the external portion of procedure (a), illustration (b),
thoracoscopic view (c). The introducer needle with a syringe with saline is used to confirm entrance into the thorax with the return of blood or air bubbles. It is
inserted in the fourth or fifth intercostal space, just above the rib to avoid injury to the neurovascular bundle.
HEAD
Fig. 3.10. A guidewire is inserted through the introducer needle and the needle is removed.
Fig. 3.11. Using the Seldinger technique, the tract is sequentially dilated after making a small skin incision for the tube.
Fig. 3.12. The tube is passed into the thoracic cavity over the guidewire.
16
Fig. 3.13. Final position of the tube after removal of the guidewire.
Removal of the chest tube trocar is associated with an increased risk of injury. Digital
exploration of the pleura to rule out adhesions reduces the
The chest tube can be removed once there is no air leak and risk of lung injury.
the output is less than 200 mL per day. The duration of the
Iatrogenic injuries to the diaphragm, liver, or the spleen
chest tube is an independent risk factor for empyema.
may occur if the tube is placed too low. Avoid this serious
The tube can be safely removed at maximal deep complication by staying at or above the fourth or fifth
inspiration or expiration.
intercostal space.
Tube misplacement is another common complication.
Autotransfusion Insertion of the tube too far into the pleural cavity may
Blood autotransfusion is fast, inexpensive relative to result in kinking and poor drainage. In a normal habitus
banked blood product, and simple. It provides the patient adult patient, do not insert the tube beyond 8–10 cm.
with safe, matched, warm blood with coagulant factors. Misplacement of the tube into the subcutaneous tissues is
There are numerous autotransfusion systems available another technical complication, especially in obese
commercially. patients.
It is recommended for use in all patients with chest trauma, Persistent air leaks can be due to technical problems or to
both blunt and penetrating, with large hemothoraces. the injury itself. Make sure that all of the tube perforations
Anticoagulant, citrate 1 mL per 10 mL of blood, can be are located within the chest cavity and that the incision
used, but is not absolutely necessary. It should be added to around the tube is tightly sealed. All connections should be
the connection with the chest tube. taped. If there are no technical problems, the differential
diagnosis should include tracheobronchial injury or
bronchopleural fistula.
Tips and pitfalls Larger size tubes do not drain more effectively. They can be
Technical complications include bleeding secondary to more painful and more difficult to insert. In adults, do not
injury of the intercostal vessels, the lung, heart, diaphragm, exceed size 28–32 Fr. For pneumothoraces, use smaller size
liver, or spleen. Insertion of the tube with the use of a chest tubes.
17
Emergency room resuscitative thoracotomy

Chapter
4 Demetrios Demetriades and Scott Zakaluzny
Surgical anatomy in the presence of cardiac tamponade or an empty heart

due to severe blood loss.
The major muscles, which are divided during resuscitative
Trauma patients arriving in the emergency room in cardiac
thoracotomy, include the pectoralis major, the pectoralis
arrest or in imminent cardiac arrest are candidates for
minor, and the serratus anterior muscles.
resuscitative thoracotomy. The indications and
Pectoralis major muscle. It originates from the anterior contraindications are controversial, with many surgeons
surface of the medial half of the clavicle, the anterior supporting strict criteria and others supporting liberal
surface of the sternum, and the cartilages of all of the criteria for the procedure. Those supporting strict criteria
true ribs. The 5-cm wide tendon inserts into the upper cite the futility of the operation and the risks to staff. Those
humerus. practicing liberal criteria cite those who do survive, the
Pectoralis minor muscle. It arises from the third, fourth, opportunity for organ donation and the educational value
and fifth ribs, near their cartilages, and inserts into the of the procedure.
coracoid process of the scapula. The emergency room resuscitative thoracotomy allows
Serratus anterior muscle. It originates from the first release of cardiac tamponade, control of bleeding, direct
eight or nine ribs and inserts into the medial part of the cardiac massage and defibrillation, aortic cross-clamping,
scapula and management of air embolism.
The left phrenic nerve descends on the lateral surface of the Endotracheal intubation, intravenous line placement, and
pericardium. resuscitative thoracotomy can be performed
The lower thoracic aorta is situated to the left of the simultaneously. The endotracheal tube may be advanced
vertebral column. The esophagus descends on the right side into the right bronchus in order to collapse the left lung
of the aorta to the level of the diaphragm, where it moves and make the procedure easier. However, this may cause
anterior and to the left of the aorta. The aorta is the first oxygenation problems in the presence of injuries to the
structure felt while sliding your fingers along the left right lung.
posterior wall towards the spine.
(See Chapter 14) Special surgical instruments
The resuscitative thoracotomy tray should be kept simple and
include only a few absolutely essential instruments, which
General principles include a scalpel, Finochietto retractor, two Duval lung for-
External cardiac compressions can produce approximately ceps, two vascular clamps, one long Russian forceps, four
20% of the baseline cardiac output and tissue perfusion. hemostats, one bone cutter, one pair of long scissors. In add-
Open cardiac massage can produce approximately 55% of ition, good lighting, working suction, and an internal defibril-
the baseline cardiac output. In traumatic cardiac arrest lator should be ready, before patient arrival. All staff should
external cardiac compression has little or no role, especially wear personal protective equipment.
18
Chapter 4. ER resuscitative thoracotomy
scissors taking care to avoid injury to the underlying

inflated lung. Right mainstem intubation or holding
ventilation during entry into the pleural cavity can
reduce the risk of lung injury. A Finochietto retractor is
then inserted and the ribs are spread. The left lower
lobe of the lung is grasped with Duval forceps and
retracted towards the patient’s head and laterally to
improve the exposure of the heart and the
thoracic aorta.
(a)
Fig. 4.1. The emergency room resuscitative thoracotomy tray should include
only the absolutely essential instruments (scalpel, Finochietto retractor, two
Duval lung forceps, two vascular clamps, one long Russian forceps, four
hemostats, one bone cutter, long scissors).
Positioning
Supine position with the left arm abducted at 90 degrees or
above the head. Antiseptic skin preparation may be performed;
however, rapid entry with release of tamponade and control of
hemorrhage trumps sterility and should take precedence over
meticulous antiseptic precautions. Draping is not required, as
it is time consuming and prevents a global view of the anatomy
and patient condition.
(b)
Incision
The left anterolateral incision is the standard incision for
resuscitative thoracotomy. It provides good exposure to the
heart and the left lung and allows cross-clamping of the
thoracic aorta. If necessary, it can be extended as a
clamshell incision into the right chest through a mirror
incision and division of the sternum.
The incision is performed through the fourth to
fifth intercostal space, at the nipple line in males or
infra-mammary fold in females. It starts at the left
parasternal border and ends at the sheets on the gurney.
Follow the curve of the ribs by aiming towards the
axilla. The pectoralis major and pectoralis minor are
encountered and divided in the anterior part of the
incision and the serratus anterior in the posterior part
of the incision.
The intercostal muscles are divided close to the superior Fig. 4.2(a),(b). The resuscitative thoracotomy incision is placed just below
the nipple in males or in the infra-mammary crease in females (through the
border of the rib, in order to avoid the neurovascular fourth to fifth intercostal space). It starts at the left parasternal border and
bundle, and the pleural cavity is entered with the use of extends to the mid-axillary line, with a direction toward the axilla.
19
(a) (b)
Pectoralis minor m
Fifth rib
Divided pectoralis major m

Upper border of the fifth rib
(c) (d)
Heart
Left axilla
Diaphragm Left phrenic nerve
Left lower lobe

of the lung
Heart
Left lower lobe
Fig. 4.3(a)–(d). Division of the pectoralis major and the underlying pectoralis minor muscles. The intercostal muscles are divided at the superior border of the
rib with scissors, taking care to avoid injury to the lung. A Finochietto retractor is placed, and the left lung and the heart are exposed. The left lower lobe of the lung
is grasped with Duval forceps and retracted towards the patient’s head and laterally to improve the exposure of the heart and the thoracic aorta.
In some patients with injuries to the right chest or the heavy scissors into a symmetrical right thoracotomy.
upper mediastinal vessels, a clamshell incision may be During the division of the sternum, both internal
needed for bleeding control and improved exposure. mammary arteries are transected, and clamping or ligation
The left thoracotomy incision is extended through a should be performed after restoration of cardiac activity
transverse division of the sternum with a bone cutter or and circulation.
20
(a) (b)
Gunshot wound
Divided sternum
Fig. 4.4(a),(b). Clamshell incision: the left thoracotomy incision is extended through a transverse division of the sternum into a symmetrical right thoracotomy.
It provides good exposure of the anterior aspect of the heart, the superior mediastinal vessels, and both lungs.
Procedure The left phrenic nerve is identified along the lateral surface
of the pericardium. In the absence of cardiac tamponade,
After entering the left pleural cavity, any free blood is
the pericardium is grasped with two hemostats anterior to
evacuated and any obvious significant bleeding from the
the nerve and a small incision is made. However, in the
lung or thoracic vessels is controlled, initially by direct
presence of tamponade the pericardium is tense and it may
pressure, and subsequently with a vascular clamp.
be difficult to apply a hemostat. In these cases a small
The next step is to open the pericardium to release any pericardiotomy is performed with a scalpel and the
tamponade, repair any cardiac injury and perform direct pericardium is then opened longitudinally and parallel to
cardiac resuscitation with cardiac massage, defibrillation, the phrenic nerve.
and the intracardiac injection of medication.
(a) (b)
Phrenic nerve
Heart
HEART
Opened pericardium
Diaphragm Diaphragm
Fig. 4.5(a)–(c). The phrenic nerve is seen on the lateral border of the pericardium and should be protected. The pericardium is opened in front
and parallel to the nerve.
21
(c)
Repaired cardiac
wound
Phrenic nerve
Left diaphragm
Fig. 4.5(a)–(c). (cont.)
Any tamponade is then released and cardiac bleeding is

controlled by finger compression between the thumb and
index finger or for large atrial injuries with a vascular
clamp. For small cardiac wounds, temporary bleeding
control may be achieved by inserting and inflating a Foley
catheter. Care should be taken to avoid accidental
dislodgement of the balloon and inadvertent puncture of
the balloon during suturing. Skin staples may be used
temporarily for stab wounds, but will be ineffective in most
cases with gunshot wounds associated with cardiac Right auricle
tissue loss.
The cardiac wound is repaired with figure-of-eight,
horizontal mattress or continuous sutures, using non-
absorbable 2–0 or 3–0 suture on a large tapered needle.
Routine use of pledgets is time consuming and unnecessary
in the majority of cases and should be reserved only in
cases where the myocardium tears during tying the sutures.
The technical details of cardiac repair are demonstrated in
Chapter 15. HEART
Open cardiac massage

Cardiac massage should always be performed using both Fig. 4.6. Atrial injuries can temporarily be controlled with a vascular clamp.
hands. Squeezing the heart with only one hand is less effective
and may result in rupture of the heart with the thumb. The
heart should be held between the two palms and compression
should proceed from the apex towards the base.
22
(a) (b)
Fig. 4.7(a),(b). In some cases with small cardiac wounds, temporary bleeding control may be achieved by inserting and inflating a Foley catheter.
Internal cardiac defibrillation Pharmacological treatment of

Internal cardiac defibrillation should be used in cases with cardiac arrest
ventricular fibrillation or pulseless ventricular tachycardia. Medications such as epinephrine, calcium, magnesium, and
The two internal cardiac paddles are placed on the anterior
sodium bicarbonate can be injected into the left ventricle as
and posterior wall of the heart and the heart is shocked with
needed.
10–50 joules.
23
Epicardial pacing wires are usually placed on the upper

part of the anterior wall of the right ventricle, one at the top
of the ventricle and the second approximately 1 cm below.
Alternatively, the wires can be placed on the left ventricle.
Epicardial wires have a small needle on one end. This
needle is used to embed the wires superficially in the
myocardium, after which the needle is cut off. Some wires
are slightly coiled to prevent easy dislodgement. A larger
needle on the other end of the wire is used to pierce the
chest wall and bring the wire to the skin surface. The
exteriorized wires are then connected to the pacer. The
usual settings for the pacer are a heart rate of 70–90 per
minute and a maximal current output of 10 mA.
(a)
Fig. 4.8. Technique of internal cardiac massage: the heart is held between the
two palms, squeezing from the apex towards the base of the heart.
RV
Opened
pericardium
Left diaphragm
Fig. 4.9. Internal defibrillation: the two internal cardiac paddles are placed on
the anterior and posterior walls of the heart.
Epicardial pacing
Intraoperative and early postoperative temporary
epicardial pacing should be considered in patients with
Fig. 4.10(a). The pacing wires are usually placed on the upper part of the
arrhythmias, in order to improve haemodynamic function anterior wall of the right ventricle, with the second wire about 1 cm below the
and suppress tachyarrhythmias. first (circle). Note repair of penetrating cardiac wound (box).
24
(b) (c)
Fig. 4.10(b). The pacing wires are brought out through the skin and
connected to the pacer.
Aortic cross-clamping
The most accessible site of the thoracic aorta for cross-
clamping is approximately 2–4 cm above the diaphragm. The
left lower lobe of the lung is grasped and retracted upwards
with a Duval clamp in order to improve the exposure of the
aorta. In cardiac arrest the aorta is collapsed and might be
difficult to distinguish from the esophagus. The aorta is the
first structure felt while sliding the fingers along the left pos-
terior wall towards the spine. The esophagus is more anterior Fig. 4.10(c). Cardiac pacer: the usual settings of the pacer are: heart rate
70–90 per minute and V output 10 mA.
and medial. The inferior pulmonary ligament may be divided
to improve exposure. The mediastinal pleura over the aorta is
then incised with long scissors and a vascular clamp is applied.
The dissection of the aorta should be kept to a minimum
seen in the coronary veins. In these cases control of the source
because of the risk of avulsion of the intercostal arteries. The
of the air should be obtained immediately, followed by needle
aortic clamp is removed as soon as the cardiac activity returns
aspiration of the air from the ventricles.
and the carotid pulse is palpable.
Air embolism Hilar occlusion

In patients with cardiac arrest or severe arrhythmias who have Consider hilar occlusion in cases with lung trauma associated
injury to the low-pressure cardiac chambers, the lung or major with severe bleeding or air embolism. Digital occlusion of the
veins, air embolism should be suspected. Sometimes, air can be hilum can be achieved by compression of the hilar structures
25
(a) (c)
Esophagus
Retracted left
lower lobe
Diaphragm
Thoracic aorta
Thoracic aorta Diaphragm
Fig. 4.11(a)–(c). (cont.)

(b)
Esophagus
Diaphragm
Thoracic aorta
Fig. 4.11(a)–(c). Cross-clamping of the thoracic aorta. The most accessible

site of the thoracic aorta for cross-clamping is about 2–4 cm above the
diaphragm. The mediastinal pleura over the aorta is incised. Note the
esophagus anteriorly and medially. A vascular clamp is applied to the aorta.
between the index finger and the thumb. A vascular clamp can
replace the digital compression.
Hilar twist
This is an alternative approach to the digital or clamp occlu-
sion of the hilum. The inferior pulmonary ligament, which is a
double layer of pleura joining the lower lobe of the lung to the
Fig. 4.12. Air embolism with air bubbles in the coronary vessels. This
mediastinum and the medial part of the diaphragm, is divided, complication should be suspected in injuries to the low-pressure cardiac
taking care to avoid injury to the inferior pulmonary vein. chambers, the lung, or major veins.
26
Incision closure and poor exposure of the upper part of the heart, (b) the
incision does not follow the curve of the ribs, (c) division of
The thoracotomy incision should be closed in the operating the intercostal muscles with the scalpel with the potential
room, as described in Chapter 14.
for injury to the underlying inflated lung, (d) injury to the
Damage control with temporary closure of the left internal mammary artery if the incision is too close to
thoracotomy incision should be considered in patients with the sternum, which can be especially problematic if not
persistent arrhythmias or who are at high risk for cardiac immediately recognized.
arrest during the ICU phase of resuscitation. In these cases
Common errors during aortic cross-clamping include (a)
immediate access to the heart for cardiac massage may be
clamping the esophagus (the aorta is the first structure felt
life-saving. Temporary incision closure is best achieved
while sliding the fingers along the left posterior wall
with the VAC technique.
towards the spine); a nasogastric tube may help in
identifying the esophagus, which is anteromedial to the
Tips and pitfalls aorta, (b) injury to the esophagus, (c) avulsion of
Common errors with the incision include (a) low incision intercostal arteries, and (d) attempting to clamp a collapsed
with an increased risk of injury to the elevated diaphragm aorta without any pleural dissection.
27
Section 3 Head
Insertion of intracranial pressure monitoring

Chapter
5 catheter
Howard Belzberg and Matthew D. Tadlock
Surgical anatomy Another useful point for the insertion of the catheter is the
Keens point, which is about 2.5 cm posterior and superior
The intracranial pressure can be monitored via a catheter to the top of the ear.
placed in one of the lateral ventricles, or with devices placed
intracranially, in the subarachnoid, subdural or epidural
spaces or in the brain parenchyma.
Intraventricular Subdural
Intraparenchymal
Kocher’s point
Midpupilllary midline
Epidural
line
Ventricle Fig. 5.2. Identification of the Kocher’s point (red X) for insertion of the ICP
monitor: Mid pupillary line, about 2 cm anterior to the coronal line.
Fig. 5.1. The intracranial pressure can be monitored via a catheter placed in
one of the lateral ventricles, or with devices placed in the epidural, subdural, or
subarachnoid spaces, or in the brain parenchyma.
General principles
The ICP monitor should be placed in the non- Insertion of ICP catheter may be performed in the
dominant hemisphere (right hemisphere in right-handed operating room, emergency room, or intensive care unit.
people). Avoid ICP placement if the INR is >1.5.
The Kocher’s point is the external skin landmark for the The Brain Trauma Foundation recommends intracranial
insertion point of the catheter; at this point, the device pressure (ICP) monitoring in salvageable victims of
insertion avoids the bridging veins, the superior sagittal traumatic brain injury (TBI) with a Glasgow Coma Score
sinus, and the motor strip, and allows the placement of the (GCS) of 8 or less and an abnormal head computed
catheter in the frontal horn of the lateral ventricle. Kocher’s tomography (CT) scan. With a normal CT scan, ICP
point is at the mid pupillary line (2–3 cm lateral to midline monitoring is recommended after TBI in patients with two
or the sagittal line) and 2 cm anterior to the coronal suture. of the following criteria: (1) age over 40, (2) motor
The coronal suture is about 11–12 cm from the base of posturing (unilateral or bilateral) (3) systolic blood
the nose. pressure < 90 mm Hg.
29
Section 3: Head
Cerebral perfusion pressure (CPP) is a calculated Special surgical instruments

physiologic measurement defined as the difference
Figure 5.3 shows the major components of a drill kit.
between the mean arterial pressure (MAP) and the ICP:
Components required for the procedure include a marking
CPP ¼ MAP – ICP. By affecting the MAP or the ICP,
pen, scalpel, self-retaining retractor, twist drill, spinal
the CPP should generally be maintained above
needle, and either a screw or catheter depending on the
60 mm Hg.
type of ICP monitoring desired. If a catheter is used, a
tunneler (included with kit) is also needed. Kits typically
Types of ICP monitoring have two different drill bits. The smaller drill bit is for
The intraventricular catheters allow therapeutic drainage of placement of a subarachnoid screw, whereas the larger bit
CSF. All other types of catheters (intraparenchymal, is for the intraventricular catheter.
subarachnoid, epidural, or subdural devices) do not allow
drainage of CSF, but they are easier to place. (a)
Intraventricular ICP monitor Twist drill

Catheter
An external ventricular drain (EVD) or intraventricular
catheter is an external flexible catheter inserted into one of
the lateral ventricles. It allows for both monitoring of ICP
and drainage of CSF as a therapeutic maneuver. A fluid
Tunneler
coupled EVD catheter is the gold standard for ICP
monitoring. The EVD is low cost and the most accurate.
Further, it is the only ICP monitor that can be recalibrated Spinal Large
in situ. needle drill bit Scalpel
Traditionally, EVDs only allowed intermittent ICP
measurements (when the drain is closed), but newer
catheters allow simultaneous ICP monitoring and CSF
drainage.
Different methods of the pressure transduction may
be utilized during EVD ICP monitoring. The basic
(and least expensive) is the fluid coupled external
mechanical transducer.
Self-retaining retractor
Intraparenchymal ICP monitor Fig. 5.3(a). Major components of a disposable twist drill kit. The ventricular
drain catheter is also shown here. The large drill bit comes with the twist drill kit.
Intraparenchymal monitors are usually placed as an
alternative to EVD placement. A fluid coupled catheter
(b)
with mechanical transducer, fiber optic transducer, or
pneumatic technology catheter can be utilized.
Intraparenchymal monitors are easier to place than the
EVD and allow for continuous monitoring.
Subarachnoid bolt
The subarachnoid screw or bolt allows for continuous
fluid coupled ICP monitoring within the subarachnoid Bolt
space.
Small
Epidural or subdural ICP monitor drill bit
These are the least accurate of the ICP monitors. Subdural
monitors utilize fluid coupled, fiber optic transducers.
Epidural monitors utilize either a fluid coupled or fiber
optic tip catheter.
Infection risk is lower with intraparenchymal monitors Fig. 5.3(b). Additional components required to place a subarachnoid bolt.
than with EVD. Note that the smaller drill bit comes with the bolt kit.
30
Chapter 5. Intracranial pressure monitoring
Patient position then made down to the bone at Kocher’s point, and the
skull is cleared of periosteum.
The patient should be positioned with the head of the bed
A self-retaining retractor (comes with the drill kit) is used
elevated at 30 degrees, with the head immobilized in a
to expose the skull below. Holding the twist drill
neutral position.
perpendicular to the skull, a burr hole is made, penetrating
both the outer and the inner tables of the skull. The stop
guard should be used to prevent accidental entry into the
Procedure brain parenchyma when the inner table of the skull is
Intraventricular ICP monitor breached. A probe/spinal needle is introduced through
the opening to ensure that the drill completely penetrated
Administer adequate analgesia and sedation. the bone. Use saline to irrigate the bone fragments in the
The hair should be clipped around the incision and exit burr hole to expose the dura matter. Using an 11-blade,
sites. Hair should not be shaved due to increased risk of make a small cruciate incision in the dura.
wound infection. The site should be prepared with
antiseptic solution and draped in the standard sterile
surgical fashion. The person performing the procedure (a)
should wear appropriate sterile gown and gloves, surgical FACE
mask, eye protection, and hair covering.
With a marking pen, mark the mid pupillary line (with
forward gaze), the sagittal line (skull midline starting at the
base of the nose), and the coronal suture. The coronal
suture is located at about 11–12 cm from the root of Kocher’s
point
the nose. Next, identify the Kocher’s point, which is
on the mid pupillary line, about 2 cm in front of the
coronal line.
(b)
Sagittal suture
Mid-pupillary line
Kocher’s point
Coronal suture
Fig. 5.4. Kocher’s point is on the mid pupillary line, about 2 cm anterior to the
coronal suture. The coronal suture is about 11–12 cm from the root of the nose.
Inject 1% lidocaine with or without epinephrine in the skin

and subcutaneous tissue for local anesthesia prior to Fig. 5.5(a),(b). A 1–2 cm incision is made at Kocher’s point, down to the
incision. An approximate 1–2 cm longitudinal incision is bone, and a self-retaining retractor is placed.
31
Section 3: Head
is encountered after three attempts, then an

intraparenchymal monitor or subarachnoid screw
should be placed.
Ipsilateral canthus
Fig. 5.6. Hold the twist drill perpendicular to the skull and make a burr hole,
penetrating both the outer and the inner tables of the skull.
Fig. 5.8. Insertion of the intraventricular catheter. Insert perpendicular to the

brain parenchyma aiming towards the inner canthus of the ipsilateral eye.
FACE Avoid excessive loss of CSF, as the brain may not

tolerate sudden decompression of the ventricles.
Make a separate skin incision, approximately
5 cm posterior to the insertion site, and tunnel the
ventricular catheter, to reduce the risk of infection. Suture
the catheter to the scalp and close the incisions with a nylon
suture. Place a sterile dressing.
(a)
Fig. 5.7. Insert a spinal needle through the burr hole to ensure complete
penetration through the bone.
FACE
The ventricular catheter is inserted perpendicular
to the brain parenchyma and aiming towards the inner
canthus of the ipsilateral eye. The catheter is advanced
5–7 cm to enter the frontal horn of the lateral ventricle.
Tunneler
Usually, a “pop” or a “give in” is felt and cerebral spinal
fluid (CSF) is encountered, indicating entry into the
ventricle. If CSF is not encountered, two additional
attempts may be made directing the catheter slightly Fig. 5.9(a),(b). Using a tunneler, the catheter is tunneled through an incision
more medial, either toward the bridge of the nose or to 5 cm posterior to the initial incision. The primary incision is sutured
the inner canthus of the contralateral eye. If no CSF with a running suture.
32
Chapter 5. Intracranial pressure monitoring
(b)
FACE
Primary incision
Fig. 5.10. Insertion of a subarachnoid bolt: the twist drill is used to make a
burr hole. Note the smaller drill bit utilized for the subarachnoid screw.
Fig. 5.9(a),(b). (cont.)
(a)
Zero the monitor at the level of external auditory
meatus.
Intraparenchymal ICP monitor

Kocher’s point should also be utilized for the placement of
intraparenchymal monitors. The depth of the insertion
depends on the area to be monitored. Once the monitor is
in place, it should be tunneled as described above.
Subarachnoid bolt
The initial incision is the same as for an EVD or
intraparenchymal monitor, but the bit for the twist drill is
wider. Once the burr hole has been made, make a cruciate Fig. 5.11(a)–(c). The subarachnoid bolt is screwed into place through
incision in the dura and open the arachnoid. The threaded the skull so that it abuts the dura. Then the transducer is placed through
bolt is placed so that it abuts the dura. the bolt.
33
Section 3: Head
(b) Epidural and subdural monitor

The preparation and location are as listed above. The
catheter is placed in either the epidural or subdural space.
Tips and pitfalls

When ventricles are compressed or displaced because
of significant brain trauma, an EVD may be difficult to
place. In the event that the ventricles are too small or
inaccessible, epidural or subdural monitors may be used.
Be wary of blood or debris obstructing the fluid column
causing inaccurate measurements. These can be flushed
with 1–2 mL of normal saline using strict sterile
precautions, but ultimately this increases the risk of
infection.
Contraindications to ICP monitoring include
coagulopathy (INR>1.5) and thrombocytopenia.
Scalp infection is a relative contraindication.
Transfuse platelets and plasma as appropriate prior to
(c) procedure to achieve an INR of 1.6 or less and a platelet
count of at least 100 000 to prevent unnecessary
hemorrhage.
Intraventricular hemorrhage is a contraindication to same
side EVD placement.
Avoid excessive loss of CSF, as the brain may not tolerate
sudden decompression of the ventricles.
Fig. 5.11(a)–(c). (cont.)
Fig. 5.12. Picture demonstrating the subarachnoid screw dressed with sterile
gauze and attached to the transducer.
34
Section 3 Head
Evacuation of acute epidural and subdural

Chapter
6 hematomas
Gabriel Zada and Kazuhide Matsushima
Surgical anatomy Subdural hematoma

There are three meninges covering the brain: the dura
mater, the arachnoid mater, and the pia mater.
The dura mater is the thickest and strongest membrane
and is firmly attached to the inner surface of the cranial Dura
bone, especially along the sutures. It contains the
meningeal arteries.
The arachnoid mater is a thin membrane under the
dura mater. Its inner surface has numerous thin Epidural
trabeculae extending downward, into the hematoma
subarachnoid space.
The pia mater is a thin membrane that covers
the surface of the brain, entering the grooves Dura
and fissures.
Due to the tight adhesion of the dura mater to the
inner skull, significant force is required to separate
them. In contrast, separation of the dura from the
subarachnoid mater can occur with relatively Fig. 6.1. Epidural hematomas develop in the space between the inner table
of the skull and the dura. Subdural hematomas develop in the space between
little force. the dura and arachnoid.
The middle meningeal artery arises from the external
carotid artery. It enters the foramen spinosum and
branches into the anterior, middle, and posterior branches
with various patterns. It is a common source of bleeding in
acute epidural hematomas (EDH). General principles
The bridging veins connect the cortical superficial veins to Acute epidural hematomas (EDH) and subdural
the sagittal sinus in the dura. They are a common source of hematomas (SDH) are commonly caused by blunt
bleeding in acute subdural hematomas (SDH). mechanisms (e.g. motor vehicle accident, fall, assault).
35
Section 3: Head
EDHs develop when blood collects in the space (b)

between the inner table of the skull and the dura;
SDHs occur when blood collects between the dura
and arachnoid.
The majority of EDHs are due to injury to the
meningeal arteries, usually the middle meningeal artery,
associated with skull fractures in the temporal region.
A torn dura venous sinus or bleeding from a skull
fracture may also result in an EDH. The hematoma is
located between the inner plate of the skull and the
Dura mater
dura mater.
Although the temporal region is the most common site for
EDHs, they may occur almost anywhere in the cranial
cavity.
(a)
Fig. 6.2(b). Appearance of the intact dura mater after evacuation of the EDH.
Note the fracture of the skull, which was the primary cause of the bleeding.
Acute SDHs are commonly caused by bleeding from brain

Edge of parenchyma injury or from torn bridging veins, which
craniectomy
connect the cortical superficial veins to the sagittal sinus in
the dura. The hematoma is located between the dura mater
EDH and the arachnoid mater.
Dura flap
(a)
Scalp flap
Skin hemostatic
Fig. 6.2(a). Appearance of a large epidural hematoma (EDH) after clips
craniectomy.
Fig. 6.3(a). Intraoperative appearance of a large subdural hematoma (SDH)

(white circle) after craniectomy and opening of the dura mater.
36
Chapter 6. Acute epidural and subdural hematomas
(b) (b)
Scalp flap
Brain
Edge of craniectomy
Fig. 6.3(b). Intraoperative appearance after evacuation of the SDH. Note the
exposed and edematous brain.
The acute EDH appears as a hyperdense lenticular

(biconvex)-shaped lesion, often associated with an Fig. 6.4(b). CT scan appearance of an acute SDH. Note the crescent
shape of the hematoma (white arrows). There is a significant midline shift
overlying skull fracture. It usually does not cross suture (black arrow).
lines. The acute SDH appears as a crescent-shaped lesion
that may cross suture lines.
Patients with EDH/SDH may present with a wide array of

(a)
clinical manifestations from mild headache to coma.
A classic “lucid interval” (brief loss of consciousness with
recovery followed by neurological deterioration) is seen in
only half of patients with acute EDH.
EDHs are typically caused by arterial sources of bleeding,
and therefore often have a more rapid time course to
neurological deterioration. Many SDHs, on the other
hand, are caused by venous sources, and may accumulate
and exert neurological effects via a slower progression
pattern.
Emergency surgical evacuation of EDHs or SDHs by
craniotomy is often required to prevent death and long-
term functional disability.
Acute SDHs, are commonly caused by bleeding from
brain parenchyma trauma or by the bridging veins that
cross the subdural space. The bridging veins connect
the cortical superficial veins to the sagittal sinus in
the dura.
Elderly people are more likely to develop SDHs due to
cerebral atrophy associated with increased fragility and
tension of the bridging veins. On the other hand, elderly
people are less likely to develop EDH because of the
fibrosis and firmer attachment of the dura mater to
Fig. 6.4(a). CT scan appearance of an acute EDH. Note the lenticular the skull.
(biconvex) shape of the hematoma (arrows).
37
Section 3: Head
Indications for surgical intervention (pneumatic) drill, burrs, and Gigli wire saw, or electric
bone saw (craniotome).
The decision for surgical evacuation of an EDH or SDH is
Head lights and surgical loupes are recommended.
typically based on an assessment of a variety of clinical,
systemic, and imaging findings. The neurological Hemostatic products (e.g., oxidized cellulose, gelatin
sponge, etc.).
examination, including the Glasgow coma scale (GCS),
pupillary findings, and motor function is a major
consideration. Systemic considerations may include (a)
restrictions due to polytrauma, hemodynamic instability,
hypocoaguable states, and comorbidities. Other objective
information that weighs on this decision-making process
includes CT imaging findings (i.e., large EDH in a patient
with only headache) and intracranial pressure (ICP)
concerns in patients with ICP monitors.
Medical management in patients with EDH or SDH, and a
concern for elevated ICPs include elevating the head of the
bed, sedation/intubation as needed, mild hyperventilation,
hyperosmolar therapy, reversal of hypocoagulable state,
seizure control, and potentially local or systemic
hypothermia.
Surgical evacuation is generally recommended for adult
patients with an EDH volume >30 cm3 on CT scan,
regardless of GCS. In many patients with GCS<9,
anisocoria on pupillary exam, thickness of hematoma
>15 mm, or midline shift >5 mm on CT scan, surgical
evacuation may also be warranted. In pediatric patients Craniotome
with acute EDH, the threshold for surgery is often lower
than in adult patients. Location of the EDH also plays an
important role, with temporal and posterior fossa EDHs
often warranting a lower threshold for evacuation because
of their propensity to cause uncal herniation and
hydrocephalus or brainstem compression, respectively. Perforator
The indication for surgical evacuation of acute SDHs often drill
includes hematoma thickness >10 mm or midline shift Hole-maker
>5 mm on the CT scan (regardless of GCS), anisocoria,
sustained ICP>20 mmHg, or decreased GCS by 2 points
from injury to admission.
Fig. 6.5(a), (b). Essential instruments for craniectomy.
Special surgical instruments

A setup for emergency craniotomy should include: Raney
scalp clips, Hudson brace hand-drill or air-powered
38
(b)
Penfield
dissectors Periosteal
elevators
Fukushima
dissector
Raney
clips & appliers
Leksell
rongeur
Forceps
Lempert
rongeur
Tenotomy
scissor
Cushing
retractor
Fig. 6.5(a), (b). (cont.)
Patient positioning Incision for craniectomy

The patient is placed in the supine position under general The entire scalp or the ipsilateral region of interest is
anesthesia with both arms tucked. The head is usually shaved, prepped, and draped. A dose of antibiotics should
elevated above the level of the heart (typically with reverse be administered prior to skin incision.
Trendelenburg position) to promote venous outflow and The exact position of the incision varies and depends on
reduce ICPs. For a posterior fossa or occipital hematoma, the location of the hematoma, but it should never reach the
prone position may be required. midline, at the top of the skull.
The patient’s head is rotated to the contralateral side of The usual incision starts at the zygomatic arch, anterior to
craniotomy, 0–15 degrees from the horizontal plane. the tragus. This is extended to (1) the summit of the pinna,
A shoulder roll is placed to facilitate head turning. This is (2) the external occipital protuberance, (3) the vertex
especially required for patients with potential cervical spine ending at the hairline. Careful consideration (and
injury who must remain in rigid collar fixation. avoidance) of midline structures must be maintained at
The patient’s head is supported with a donut pillow or all times.
horseshoe headholder. Mayfield pin fixation systems are
not required for most cases in supine position.
39
Section 3: Head
Fig. 6.6. Skin incision is made starting at the

zygomatic arch anterior to the tragus to the vertex,
ending at the hairline (question mark incision). The
Right ear incision should avoid the midline, at the top of
the skull.
Face
Major scalp bleeding is controlled with the electrocautery, muscle are split, and the scalp/temporalis
and Raney clips are applied to achieve hemostasis along the musculocutaneous flap are elevated together to avoid
edge of the scalp incision. The temporalis fascial and injury to the frontalis branch of the facial nerve.
Fig. 6.7. A musculocutaneous flap is made to

expose the skull for craniotomy. The scalp/
temporalis musculocutaneous flap are opened
together to avoid injury to the frontalis branch of
the facial nerve.
Scalp flap
Temporal muscle
Skull
40
Fig. 6.8. Application of Raney clips on the edges

of the incised scalp achieves hemostasis.
Skull
Tips and pitfalls Burr holes and bone flap removal

Maintain awareness of the location of the midline at all For patients with large, hemispheric lesions (usually SDH),
times. Avoid midline at the top of the skull to prevent four burr holes are created using either a hand drill or a
injury to the sagittal sinus. pneumatic/electric drill. Burr holes are placed in the
Be careful to avoid injury to the frontal branch of the (1) temporal squama, (2) parietal area, (3) frontal area,
facial nerve, located 1 cm anterior to the tragus. (4) pterion (area behind the zygomatic arch of the
frontal bone).
Fig. 6.9. Sites of the burr holes for large,

hemispheric lesions.
Right ear
Scalp flap
Behind the zygomatic arch
Temporal squama
Parietal area
Frontal area
41
Section 3: Head
In patients with localized/confined EDH The pneumatic drill bit stops spinning on penetrating
(i.e., temporal EDH), three burr holes can be the inner table of the skull. A curette or rongeur is used
placed surrounding the confines of the hematoma. to remove the remaining bone fragments.
(In cases of EDH, the hematoma is often The dura is dissected off the inner table of the skull using a
encountered immediately following placement of the Penfield dissector or angled Fukushima instrument to
burr hole.) prevent the violation of the dura and brain tissue
The Burr holes can be created using a hand-held or a underneath. Bony bleeding is controlled with bone wax.
pneumatic drill. The drill is always placed perpendicular to The burr holes are then connected using an air-powered
the skull. bone saw (craniotome). A thin metal strip can be placed
The hand-held drill should be advanced carefully with a between the skull and the dura. The craniotome also has a
pointed bit (first bit) until the inner table is penetrated protective footplate. The bone flap is subsequently removed
and the dura is barely exposed. Then the drill bit with carefully from the underlying dura. Again, great care should
more of a curvature (second/third bit) is used to widen be taken to avoid midline structures (sagittal sinus) with this
the hole. step. The bone flap is preserved in a sterile location.
Fig. 6.10. The dura is dissected off the inner skull

using a dissector.
Fig. 6.11. Burr holes are connected with a bone

saw to create a bone flap.
42
(a) Fig. 6.12(a). A bone flap is removed with

attention to avoid injury to sagittal midline
Dura
Subdural hematoma
Dura
Epidural
hematoma
Dura
Fig. 6.12(b). Exposure of the dura mater after removal of the bone flap.
In patients with EDH, the hematoma can be evacuated at Tips and pitfalls
this time. The offending (bleeding) vessel can be identified
To avoid injury of the superior sagittal sinus or arachnoid
and coagulated at this time. The dura is tacked up to the
granulation by making the burr holes in the frontal and
surrounding bone to prevent reaccumulation of
parietal area, these holes should be created at least 1–2 cm
hematoma.
off the midline.
In cases of SDH, the durotomy is created in a cruciate,
Additional bone removal at the temporal base may be
stellate, or semicircular fashion. The dura is tacked up, and
performed using a single-action or double-action rongeur
the hematoma is evacuated using gentle suction and
to achieve complete decompression of the medial temporal
irrigation.
structures (uncus), ambient cisterns, and brainstem.
43
Section 3: Head
(a) Evacuation of hematoma and bleeding

control
The main purposes of surgery for this particular indication
are evacuation of hematoma, establishment of hemostasis,
and prevention of reaccumulation of hematoma.
Aggressive reversal of coagulopathy using blood products
(e.g., fresh frozen plasma, recombinant factor VIIa,
prothrombin complex concentrate, platelets) should be
considered.
Once the hematoma is encountered, the clot is removed
with forceps, irrigation, and/or suction. The source of
bleeding can be from (1) arterial injury, (2) venous injury,
(3) brain parenchymal injury, (4) bony bleeding, (5)
Dura mater venous sinus bleeding. The bleeding site may not always be
identified at the time of surgery (particularly venous
bleeding that has thrombosed/clotted by the time of surgery).
Arterial bleeding can be cauterized using a bipolar
coagulator. Avoid cauterizing intact veins, as extensive
venous infarction may occur. Several types of topical
hemostatic agents (e.g., oxidized cellulose, gelatin sponge)
can be used to achieve hemostasis.
Tips and pitfalls

Great care must be taken to avoid the iatrogenic injury to
the brain parenchyma when hematoma is evacuated using
a suction tip or any other instruments. Any variety of
cottonoids can be used to protect the brain.
To control bleeding outside the area of exposure,
additional removal of bone may be required. Attempting to
achieve hemostasis without direct observation (i.e. under
surrounding bone), which may cause further injury to
vessels or brain parenchyma, should be avoided.
(b)
Closure
Once the hematoma is evacuated and bleeding is stopped, a
Valsalva maneuver can be performed to verify that
hemostasis has been achieved.
In EDH cases, a small durotomy may be made to rule out
the presence of SDH.
When possible, the dura is closed in a watertight manner.
In cases with significant brain edema, the bone flap is often
not replaced (craniectomy), and a dural substitute overlay
is often used to protect the brain prior to scalp closure.
A decision should be made whether to replace the bone flap,
and whether any epidural drains would be of benefit to the
patient. Our preference is to use round drains (Blake or
round Jackson–Pratt drains) when necessary, which are more
Fig. 6.13(a), (b). For evacuation of a subdural hematoma, the dura is opened easily removed at the bedside. Drains can be tunneled out of a
in a cruciate, stellate, or semi-circular fashion. burr hole and through the scalp lateral to the incision.
44
To prevent the development or recurrence of EDH A separate drain can be placed underneath the galea as
postoperatively, the dura can be tacked up to the needed. The temporalis fascia is reapproximated.
surrounding bone in a circumferential manner by Following irrigation, closure of scalp proceeds in two layers
drilling small holes in the surrounding bony edges, and (galea aponeurotica, skin).
suturing the dura to these holes using 4–0 Neurilon sutures.
Intracranial cerebral pressure (ICP) monitoring may be a
useful adjunct, and a monitor can be placed (often
contralateral to the operative site) prior to, during, or Tips and pitfalls
following the operation. In cases of significant brain edema, the bone
When indicated, the bone flap is replaced and secured flap should not be replaced (decompressive
using standard bone fixation plates. This is not possible in craniectomy).
the presence of severe brain swelling.
Fig. 6.14. The bone flap is placed after the

evacuation. For severe swelling of the brain, the
bone flap is left out.
Skull flap
45
Section 4 Neck
Neck operations for trauma: general principles

Chapter
7 Emilie Joos and Kenji Inaba
Surface anatomy Zone I: from the sternal notch to the cricoid

cartilage.
For trauma purposes, the neck is divided into three distinct
Zone II: from the cricoid to the angle of the
anatomical zones. Although these zones do not directly
mandible.
impact clinical decision making, they are important for
documentation and communication purposes. Zone III: from the mandible to the base of the skull.
Zone III Zone III
Zone II Zone II
Zone I Zone I
Fig. 7.1. For trauma purposes, the neck is divided into three distinct anatomical zones: Zone I, from the sternal notch to the cricoid cartilage; Zone II, from the
cricoid to the angle of the mandible; Zone III, from the mandible to the base of the skull.
47
Section 4: Neck
At the level of the superior border of the thyroid cartilage Overall, approximately 20% of gunshot wounds and 10% of
the common carotid artery bifurcates into the internal and stab wounds require operation. The remaining patients
external carotid arteries. can be managed non-operatively.
At the level of the angle of the mandible, the internal and Patients with hard signs of vascular injury (pulsatile bleeding,
external carotid arteries are crossed superficially by the large or expanding hematoma, bruit or thrill, and shock)
hypoglossal nerve and the posterior belly of the digastric or aerodigestive tract injury (hemoptysis, hematemesis,
muscle. air bubbling), should proceed directly to the OR.
The external landmark of the pharyngoesophageal and Asymptomatic patients can be observed with local
laryngotracheal junctions is the cricoid cartilage. On wound care. All remaining patients with soft signs of
esophagoscopy, this is located 15 cm from the upper vascular or aerodigestive tract injury should undergo CT
incisor teeth. angiography with the selective use of catheter-based
The inferior border of the middle of the clavicle is the angiography, endoscopy, and contrast swallow for
external landmark for the transition of the subclavian equivocal CT results.
artery to the axillary artery. About 10% of patients with penetrating neck
trauma present with airway compromise due to direct
trauma to the larynx or trachea or due to external
General principles compression by a large hematoma. Airway
establishment can be a difficult and potentially dangerous
Overall, approximately 35% of all gunshot wounds and 20% procedure. The surgeon should be ready to perform a
of stab wounds to the neck result in significant injuries to surgical airway.
vital structures. Transcervical gunshot wounds are associated Bleeding from a deep penetrating injury to
with the highest incidence of significant injuries. the neck may be controlled by direct digital pressure
In penetrating trauma, the most commonly injured in the wound or placement of a Foley catheter
structures are the vessels, followed by the spinal cord, into the wound and inflation of the balloon with
aerodigestive tract, and nerves. sterile water.
(a) (b)
Fig. 7.2(a), (b).
48
Chapter 7. Neck operations for trauma
(c) (d)
Fig. 7.2(c),(d).
Fig. 7.2(a-d). Bleeding from a deep penetrating injury to the neck may be controlled by placement of a Foley catheter into the wound and inflation of the balloon
with sterile water.
Always place intravenous lines in the arm opposite the (a)

injury, especially in periclavicular injuries with suspected
subclavian vein injury. Suprasternal
In suspected major venous injury, place patient in the notch
Trendelenburg position and occlude the wound with gauze,
in order to reduce risk of air embolism.
Positioning
The patient should be in the supine position.
If the cervical spine has been cleared, a roll should be
placed under the shoulders to provide extension of
Mastoid
the neck.
If a sternocleidomastoid incision is planned, the head is
slightly extended with the placement of a shoulder roll and
turned to the opposite side of the injury. For a collar
incision the head is kept in the midline position.
Fig. 7.3(a). Position of patient for a sternocleidomastoid incision: the head is
slightly extended with the placement of a shoulder roll and turned to the
opposite side of the injury.
49
Section 4: Neck
(b) vessels. A median sternotomy may be added to the sternoclei-

domastoid or the clavicular incisions for more proximal con-
trol of the common carotid or subclavian arteries.
Suprasternal
notch
Fig. 7.3(b). Position of patient for a collar incision: the head is kept in the
midline position and slightly extended with the placement of a shoulder roll.
Special instruments
A rigid or flexible endoscope should be available for
intraoperative esophagoscopy if necessary.
Fig. 7.4. Anterior sternocleidomastoid, clavicular, and median sternotomy

Skin preparation incisions.
Prepare the patient’s neck from ear to ear including chin,
chest for possible sternotomy or thoracotomy, and both
groins for possible vein harvesting.
Peri-operative antibiotics should be given. Anterior sternocleidomastoid incision
Towels should be placed in the recesses above the This incision is made over the anterior border of the
shoulders. sternocleidomastoid muscle and extends from just below
A clear drape should be placed from the chin upwards, so the mastoid to the suprasternal notch.
that the airway is visible and accessible to the surgeon and
This versatile incision can be extended down to the
to facilitate joint airway manipulation with anesthesia. sternum for access to the thoracic inlet and up to the
mastoid process to expose the vertebral artery and the
Incisions distal internal carotid artery. Bilateral incisions can be
Three major incisions allow access to the neck: the anterior joined with a collar incision, providing complete access to
sternocleidomastoid, the clavicular, and the collar incision. all neck structures.
The former is versatile and used in most cases. The collar This incision provides good access to the carotid arteries,
incision is used in limited circumstances for central injuries. the jugular vein, the vertebral artery, and the cervical
The clavicular incision is used for exposure of the subclavian aerodigestive tract.
50
Chapter 7. Neck operations for trauma
Fig. 7.5. The sternocleidomastoid incision is

made over the anterior border of the
sternocleidomastoid muscle, and extends from
just below the mastoid to the suprasternal notch.
Anterior border of
left SCM muscle
Collar incision
The collar incision is made approximately two finger
breadths above the sternal notch, extending to the medial
borders of the sternocleidomastoid muscles.
This is the preferred incision if the injury is central.
It is commonly used for repair of a central airway injury.
When a skin wound exists, it can be incorporated into the
incision. Head
This incision can also be extended to either side.
Clavicular incision
This is the standard incision for the exposure of the
subclavian vessels on both the right and the left. It may
be combined with a median sternotomy, for exposure
of the proximal subclavian vessels or upper mediastinal
vascular structures.
It begins at the sternoclavicular junction, extends over
the medial half of the clavicle, and at the middle portion
of the clavicle it curves downwards into the
deltopectoral grove.
The clavicle may be divided near the sternum and retracted
to expose the proximal subclavian artery. Further details
can be found in the chapter addressing subclavian injuries.
Suprasternal notch
Fig. 7.6. The collar incision is made approximately two finger breadths
above the sternal notch, extending to the medial borders of the
sternocleidomastoid muscles.
51
Section 4: Neck
Tips and pitfalls

Airway compromise due to direct trauma to the larynx or
trachea or due to external compression by a large
hematoma is an emergency. The surgeon should be ready
to perform a surgical airway.
Never place an intravenous line in the arm on the same side
as a periclavicular injury, because of the possibility of the
presence of a subclavian venous injury.
Air embolism may occur in patients with major venous
injury. To prevent this potentially lethal complication,
place the patient in the Trendelenburg position and
occlude the wound with gauze.
Always prepare the chest, as injuries in the neck may track
down towards the mediastinal structures, requiring a
sternotomy for control and repair. Specifically, a
Fig. 7.7. The clavicular incision begins at the sternoclavicular junction, extends
sternotomy can be extremely helpful for proximal control
over the medial half of the clavicle, and at the middle portion of the clavicle it of the great vessels.
curves downwards into the deltopectoral groove. All of the access incisions are extensible and can be
combined, maximizing exposure and facilitating a high
quality repair and decreasing the rate of missed or
iatrogenic injuries.
For the esophagus and trachea, take care to avoid missing a
second backwall injury, as it can be difficult to detect with a
lateral incision.
Fig. 7.8. The clavicular incision can be combined with a median sternotomy
for improved exposure of the proximal left subclavian artery and upper
mediastinal vessels.
52
Section 4 Neck
Carotid artery and internal jugular vein injuries

Chapter
8 Edward Kwon, Daniel J. Grabo, and George Velmahos
Surgical anatomy The carotid sheath and its contents are covered
superficially by the platysma, the anterior margin of the
The right common carotid artery originates from the sternocleidomastoid muscle, and the omohyoid muscle.
innominate (brachiocephalic) artery. The external
Deep to the vessels are the longus colli and longus capitis
landmark is the right sternoclavicular joint. The left
muscles. Medial to the carotid sheath are the esophagus
common carotid artery originates directly from the aortic
and the trachea.
arch in the superior mediastinum.
At the level of the superior border of the thyroid cartilage,
The carotid sheath contains the common and internal carotid the common carotid artery bifurcates into the internal and
arteries, the internal jugular vein, and the vagus nerve. The
external carotid arteries.
internal jugular vein lies lateral and superficial to the
The facial vein crosses the carotid sheath superficially to
common carotid artery and vagus nerve. The vagus nerve lies
enter the internal jugular vein at the level of the carotid
posteriorly, between the artery and the vein. On occasion,
bifurcation.
the vagus nerve may be located anterior to the vessels.
The external carotid artery lies medial to the
Digastric m Hypoglossal n internal carotid artery for the majority of their course.
The first branch of the external carotid artery is the
superior thyroid artery located near the carotid
bifurcation.
The internal carotid artery does not have any extracranial
branches.
At the level of the angle of the mandible, the
ICA internal and external carotid arteries are crossed
superficially by the hypoglossal nerve (cranial nerve XII)
ECA
Facial v and the posterior belly of the digastric muscle. The
CCA glossopharyngeal nerve (cranial nerve IX) passes in
IJV front of the internal carotid artery, above the
hypoglossal nerve.
The external carotid arteries terminate in the parotid gland,
Omohyoid m where they divide into the superficial temporal and
maxillary arteries.
At the level of the skull base, the internal carotid
arteries cross deep and medial to the external carotid
arteries to enter the carotid canal behind the styloid
process.
Fig. 8.1. Surface anatomy and key anatomical relationships of the
carotid artery.
53
Section 4: Neck
Common carotid artery Vagus nerve Fig. 8.2. Carotid sheath contents. The carotid
sheath contains the common carotid and internal
carotid arteries medially, the internal jugular vein
laterally, and the vagus nerve posteriorly between
the vessels.
LEFT FACE
Internal jugular vein
Internal jugular vein Facial vein Fig. 8.3. The facial vein is the anatomical
landmark approximating the location of the carotid
bifurcation deep to it. The facial vein is ligated and
divided in order to mobilize the internal jugular
vein laterally and provide exposure to the
underlying carotid bifurcation.
LEFT FACE
54
Chapter 8. Carotid artery/internal jugular vein injuries
External carotid artery Superior thyroid artery Lingual artery Fig. 8.4. The external carotid lies medial to the
internal carotid artery and gives several branches
(the first branches are the superior thyroid and
lingual arteries). The internal carotid artery has no
extracranial branches. Note the hypoglossal nerve
(yellow loop) crossing over the two arteries.
Common carotid artery
Internal jugular vein Hypoglossal nerve
LEFT EAR
Internal carotid artery
Hypoglossal nerve CN XII Posterior belly of digastric muscle Fig. 8.5. Distal carotid artery anatomy. At the
angle of the mandible, the carotid arteries are
crossed superficially by the hypoglossal nerve, the
posterior belly of the digastric muscle, and the
glossopharyngeal nerve.
Stylohyoid muscle
External carotid artery
LEFT EAR
Glossopharyngeal nerve CN IX
General principles ischemic infarct into a hemorrhagic infarct leading to

A preoperative neurologic examination should always be increased morbidity and should therefore be avoided.
performed and documented. If technically possible, all common and internal carotid
Patients with neurologic deficits secondary to carotid artery injuries should be repaired, as ligation is associated
artery injury have a poor prognosis. If the diagnosis is with a significant risk of stroke. Ligation may be
made early (within 4–6 hours), revascularization should be considered in the comatose patient with delayed operation
performed. Delayed revascularization can convert an (>6 hours from injury) or if there is uncontrollable
55
Section 4: Neck
hemorrhage. Temporary shunt placement is a preferred segment of the carotid arteries or internal jugular veins
method of damage control for these injuries. may be required, a chest tray, sternal saw, and sternal
Prophylactic shunting of the common or internal carotid retractor should always be available. 1% lidocaine should
arteries should be considered intraoperatively in patients also be readily available for possible injection of the carotid
requiring reconstruction with grafts. body if necessary, as well as prosthetic graft materials
Minor carotid injuries, such as small intimal tears, may be (PTFE or Dacron) in the event that reconstruction requires
managed non-operatively with antithrombotic therapy and a conduit.
imaging to document resolution. Headlights and surgical loupes are strongly recommended.
Select patients with extremely proximal or distal carotid
injuries may be best managed with angiographically placed Positioning
stents.
The patient is positioned supine on the operating room
The external carotid artery can be ligated without table with adduction of the ipsilateral arm or bilateral arms
significant sequelae. if the neck injuries are bilateral.
Systemic heparinization (100 u/kg) should be considered in The neck should be slightly extended and the head turned
patients with no other injuries. Alternatively, heparin saline to the contralateral side. If possible, elevation of the
solution (5000 units in 100 mL normal saline) can be shoulders with a shoulder roll will facilitate extension of
injected locally, both proximal and distal into the injured the neck.
vessel.
The patient should be prepped to include the entirety of the
Unilateral internal jugular vein injuries can be repaired if neck from the earlobes to the base of the skull and
the patient condition allows and if there is no significant extending to the inferior aspect of the mandible down to
stenosis (<50%). However, unilateral ligation is well the chest. The chest should be included to facilitate
tolerated. If there are bilateral internal jugular vein injuries, proximal control. The groins should also be included in the
at least one vein should be repaired. field, in case a saphenous vein graft is required.
Vascular repairs should be protected in the presence of
tracheal or esophageal injuries with interposed tissue,
usually the strap muscles.
Incisions
The standard incision for exposure to the cervical carotid
arteries and internal jugular veins is a longitudinal incision
Special surgical instruments along the anterior border of the sternocleidomastoid
Complete vascular tray, Fogarty catheters, a carotid shunt, muscle, extending from the suprasternal notch to just
and rummel tourniquets. As exposure of the mediastinal below the mastoid process.
Fig. 8.6. The patient is positioned with the neck

Suprasternal extended and the head rotated contralateral. A roll
notch under the shoulders may be helpful to achieve
maximal extension of the neck. The standard
incision is placed along the anterior border of the
sternocleidomastoid muscle from the suprasternal
notch to the mastoid process.
Sternocleidomastoid muscle
56
For proximal common carotid artery or internal jugular retracted laterally. At the upper part of the incision, the
vein injuries, the combination of a sternocleidomastoid accessory nerve (cranial nerve XI) enters the
incision and median sternotomy provides the optimal sternocleidomastoid muscle and care should be taken to
exposure (see Chapter 16). avoid injury.
The carotid sheath is now visible and is incised along its
Operative technique length. If more proximal exposure is required, the
omohyoid muscle may be divided.
Exposure The contents of the carotid sheath are now exposed.
A longitudinal incision is made along the anterior border The internal jugular vein is then mobilized and retracted
of the sternocleidomastoid muscle from the mastoid laterally and the common carotid artery is retracted
process to the suprasternal notch. The incision is carried anteromedially. The vagus nerve, located posteriorly
through the platysma to expose the anterior border of the between the vessels, is identified and protected. Vessel
sternocleidomastoid muscle. loops are placed around the artery, vein, and nerve. For
The anterior border of the sternocleidomastoid exposure of the carotid bifurcation, the facial vein is
muscle is then dissected free along its length and identified and ligated.
Platysma Fig. 8.7(a). The skin is incised along the anterior

(a)
border of the sternocleidomastoid muscle to
expose the underlying platysma.
LEFT FACE
57
Section 4: Neck
(b) Fig. 8.7(b). The sternocleidomastoid is dissected

along its anterior border and retracted laterally.
Small branches of the external carotid artery (white
arrows) are ligated and divided to adequately
mobilize the sternocleidomastoid muscle and
expose the carotid sheath.
LEFT FACE
Sternocleidomastoid muscle reflected posterior
omohioideo Fig. 8.8(a). Carotid sheath and omohyoid. The

(a) Omohyoid muscle Intact carotid sheath
está distal sternocleidomastoid muscle is retracted posterior
to reveal the underlying carotid sheath and its
contents. The omohyoid muscle at the inferior
border of the incision may be divided if more
LEFT FACE proximal exposure is required.
Sternocleidomastoid muscle retracted posterior
58
(b) Fig. 8.8(b). Exposure to the proximal common

carotid artery and internal jugular vein may be
improved with division of the omohyoid muscle.
LEFT FACE
Omohyoid muscle
divided
LEFT
EAR
Common carotid artery Fig. 8.9. Carotid sheath contents. The common
carotid artery and internal jugular vein are identified
and looped. The vagus nerve is identified posterior
and between the vessels (yellow loop).
LEFT FACE
Vagus nerve Internal jugular vein
59
Section 4: Neck
During dissection of the carotid bifurcation, the carotid The ansa cervicalis should be visible anterior to
body may be stimulated causing hemodynamic instability the carotid bifurcation and can be followed to the
(hypotension and bradycardia). If this is encountered, the hypoglossal nerve. Once the hypoglossal nerve
carotid body may be injected with 1% lidocaine. The (cranial nerve XII) is identified and protected, the
external and internal carotid arteries are then dissected and ansa cervicalis may be divided if necessary for
isolated using vessel loops. exposure.
Common carotid artery External carotid artery Carotid body Fig. 8.10. Carotid body injection. During the
dissection of the carotid bifurcation, the carotid
body may become stimulated causing hypotension
and bradycardia. If this situation is encountered, 1%
lidocaine may be injected into the carotid body
located in the crotch of the bifurcation.
Internal carotid artery Hypoglossal nerve
(a) Fig. 8.11(a). The carotid bifurcation is carefully

dissected and the common, internal, and external
carotid arteries are isolated and looped. Note that
the external carotid artery is medial to the internal
carotid artery at the bifurcation.
60
(b) Fig. 8.11(b). Hypoglossal nerve and ansa

cervicalis. The ansa cervicalis overlies the carotid
Common carotid artery External carotid artery bifurcation and may be followed to identify the
Ansa cervicalis hypoglossal nerve. The hypoglossal nerve crosses
Hypoglossal nerve CN XII
the internal and external carotid arteries distal to
the bifurcation.
Vagus nerve
CN X
Exposure of the distal internal carotid artery is challenging Exposure to internal carotid at the base of the skull is
and may require techniques such as subluxation of the achieved by extending the surgical incision posteriorly
mandible and possibly mandibular osteotomy. around the ear and dividing the posterior belly of the
Subluxation of the mandible may be achieved by digastric, stylohyoid, stylopharyngeus, and styloglossus
grasping the lower teeth with two hands and pulling the muscles. The styloid process is then removed. Care
mandible downward and anteriorly. An assistant may should be taken to avoid injury to the glossopharyngeal
hold the jaw in position as the surgeon exposes the nerve (cranial nerve IX) deep to the posterior digastric
vessel. and along the stylohyoid muscle.
61
Section 4: Neck
Fig. 8.12. Left distal carotid artery exposure.

To expose the carotid artery and internal jugular
vein close to the base of the skull the incision is
extended in a postauricular fashion and the
mandible is then subluxed and wired or held by an
assistant to maintain subluxation.
LEFT FACE
Common carotid artery
Extension of incision for distal exposure
(a) Hypoglossal nerve Fig. 8.13(a). Distal carotid exposure. Subluxation

of the mandible is achieved, allowing more distal
exposure of the internal carotid artery. The
Stylohyoid muscle posterior belly of the digastric muscle and
Posterior belly of stylohyoid muscles overlie the distal internal
carotid artery. Deep to the muscle lies the
digastric muscle
Glossopharyngeal nerve LEFT EAR

62
Division of the posterior belly of Fig. 8.13(b). Division of the posterior belly of the
(b) digastric muscle digastric muscle. Care should be taken to avoid
injury to the underlying glossopharyngeal nerve
during division.
Hypoglossal nerve
Glossopharyngeal nerve
Division of stylopharyngeus muscle Fig. 8.14(a). Division of the stylopharyngeus. The

stylopharyngeus muscle is divided to continue
(a) exposure to the distal carotid artery. Care should be
taken to avoid injury to the underlying
Hypoglossal
nerve
Divided posterior belly

Glossopharyngeal nerve
of digastric muscle
63
Section 4: Neck
(b) Fig. 8.14(b). Once the stylopharyngeus is

divided, the underlying styloglossus and stylohyoid
ligaments are identified and divided. Care should
Hypoglossal nerve CN XII
Styloglossus muscle be taken to avoid injury to the underlying
Stylohyoid ligament
Styloid process
Glossopharyngeal nerve CN IX
Internal carotid artery Division of styloid process Fig. 8.15(a). Styloid process. Once the muscles
are divided, the styloid process is divided with a
(a) rongeur to gain exposure to the internal carotid
artery at the carotid canal.
Hypoglossal
nerve CN XII
Glossopharyngeal nerve CN IX External carotid artery
64
(b) Fig. 8.15(b). Internal carotid artery at carotid

canal. With the jaw subluxed and the styloid
Hypoglossal nerve CN XII Facial artery Internal carotid artery at carotid canal muscles and process divided, the internal carotid
artery is exposed as it enters the carotid canal. Note
the course of the internal carotid as it crosses deep
and medial to the external carotid artery. The
termination of the external carotid artery into the
parotid gland is also well exposed.
Internal carotid artery Glossopharyngeal nerve CN IX External carotid artery
Exposure to proximal cervical carotid or jugular injuries mobilization and primary suturing with 5–0 monofilament
may require the addition of a sternotomy to the standard non-absorbable suture. The intima should be inspected
sternocleidomastoid incision. This technique is described through the injury to ensure back wall integrity prior to
in the chapter on mediastinal vascular injuries. closure.
Carotid shunts should be utilized during more
complex repairs to protect against ischemic
Repair stroke.
Small carotid artery injuries without significant tissue loss
(usually secondary to knife wounds) may be repaired by
Temporary carotid shunt Fig. 8.16. Temporary carotid shunt. A temporary

carotid shunt should be used for repairs of the
carotid artery more complex than lateral
arteriorrhaphy. The shunt may be secured with
External carotid artery rummel tourniquets, allowing continued cerebral
perfusion during reconstruction to prevent
ischemia.
Rummel tourniquets
65
Section 4: Neck
If the repair is not possible without causing stenosis, a For destructive injuries with significant tissue loss (usually
patch angioplasty can be performed using either a vein secondary to firearm injuries or blunt trauma), an
patch (saphenous vein or external jugular vein) or interposition graft with either reverse saphenous vein or
prosthetic material (Dacron, PTFE, bovine pericardium) prosthetic material (Dacron, PTFE) should be used.
sutured in a running continuous fashion circumferentially Alternatively, transposition of the external carotid artery
around the defect using a 5–0 monofilament non- may be possible in select circumstances to reconstruct the
absorbable suture. internal carotid artery injury.
(a) Graft in progress with shunt in place Fig. 8.17(a). Graft reconstruction with temporary
shunt. A temporary shunt is placed in the lumen of
the injured vessel to maintain cerebral perfusion,
while a graft is sutured in place. Note that the same
technique may be used during a patch angioplasty
reconstruction.
(b) Fig. 8.17(b). Interposition graft. Once the graft is

Completed graft
anastomosed, the temporary shunt is removed.
Possible conduits include reverse saphenous vein,
PTFE, and dacron.
66
Proximal external carotid artery Anastomosis Fig. 8.18. External to internal carotid
transposition. In rare circumstances transposition of
the external carotid artery proximal to the injury to
the distal internal carotid artery may be used to
reconstruct the injured vessel.
Ligated distal external

carotid artery
Ligated proximal Distal internal carotid artery

internal carotid artery
If the patient is not stable enough to undergo definitive to maintain cerebral blood flow during the resuscitative
repair of the carotid vessels, a carotid shunt may be placed period with delayed reconstruction.
Damage control shunt Fig. 8.19. Damage control carotid shunt. The
shunt is secured with silk ties around the proximal
and distal arterial segments as well as the shunt
itself, to prevent migration of the shunt.
67
Section 4: Neck
Internal jugular vein injuries may be repaired if Tips and pitfalls

technically feasible and if repair does not result in stenosis
In patients with neurologic deficits secondary to carotid
greater than 50%. If there is unilateral injury and the
artery injury, revascularization should be performed within
patient is unstable, then ligation is appropriate. If
4–6 hours of the injury. Delayed revascularization after this
there are bilateral injuries to the internal jugular veins,
time period can convert an ischemic brain infarct into a
then attempts should be made to repair one side if at
hemorrhagic infarct.
all possible.
Subluxation of the mandible is not difficult and may
improve the exposure of the distal internal carotid artery
by an additional 2–3 cm.
Wound closure Distal control of internal carotid injuries at the level of the
The wound should be closed in layers with base of the skull may require balloon catheter tamponade
reapproximation of the sternocleidomastoid muscle, and thrombosis or ligation as the definitive management if
platysma, and skin over a closed suction drain. it is not possible to revascularize distally secondary to
anatomical barriers.
68
Section 4 Neck
Subclavian vessels
Chapter
9 Demetrios Demetriades and Jennifer Smith
Surgical anatomy may have a common origin with the left common
On the right side, the subclavian artery originates from carotid artery.
the innominate (brachiocephalic) artery, which branches The subclavian artery courses laterally, passing between the
into the right subclavian and right common carotid anterior and middle scalene muscles. This is in contrast to
arteries. On the left side, it originates directly from the the subclavian vein, which is located superficial to the
aortic arch. In some individuals the left subclavian artery anterior scalene muscle.
Left common carotid artery Fig. 9.1. The right subclavian originates from the
Right common carotid artery
innominate artery and the left subclavian directly
from the aortic arch. Note the major branches of
Costocervical artery the subclavian artery.
Thyrocervical trunk
Vertebral artery
Right subclavian artery Left subclavian artery
Innominate artery Internal thoracic artery
Aortic arch
69
Section 4: Neck
sternocleidomastoid and the strap muscles. It gives rise to

the vertebral, internal mammary (internal thoracic), and
thyrocervical arteries. The second part lies deep to the
Middle scalenus
anterior scalene muscle and superficial to the upper and
middle trunks of the brachial plexus. Here, it gives rise to
the costocervical artery (on the left side the costocervical
Phrenic nerve
artery comes off the first part of the subclavian artery). The
third part is located lateral to the anterior scalene muscle,
Anterior scalenus and courses over the lower trunk of the brachial plexus,
usually giving rise to the dorsal scapular artery, although its
branches are not constant.
T1
Vagus nerve
Anterior scalenus
Right common carotid

Phrenic nerve
Vertebral artery
Internal thoracic
First rib
artery Thyrocervical trunk
Innominate artery
First rib
Fig. 9.2. The subclavian vein is anterior to the anterior scalene muscle and the
artery is posterior. Notice the phrenic nerve on the anterior surface of the muscle.
The brachial plexus is between the anterior and middle scalene muscles.
Fig. 9.3. Anatomy and branches of the right subclavian artery. Note the
The subclavian artery is divided into three parts on the three branches of the first part of the artery (vertebral and thyrocervical
basis of its relationship to the anterior scalene muscle. The arteries coursing superiorly, and the internal thoracic artery coursing inferiorly).
The phrenic nerve crosses over the anterior scalenus muscle and lies lateral
first part extends from its origin to the medial border of the to the internal thoracic artery. The vagus nerve is medial to the internal
anterior scalene muscle, coursing deep to the thoracic artery.
Fig. 9.4. Branches of the first part of the left

subclavian artery, shown after division of the
anterior scalene muscle: vertebral a., internal
thoracic a., and thyrocervical trunk.
Thyrocervical trunk
Vertebral a.
Internal mammary a.
Subclavian a.
70
Chapter 9. Subclavian vessels
The subclavian artery continues as the axillary artery, as it The vagus nerve is in close proximity to the first
passes over the first rib. The external landmark for this part of the subclavian artery and it lies medial to the
transition is the lower border of the middle of the clavicle. internal thoracic artery. On the right side, it crosses
The external landmark for the axillary artery is a curved in front of the artery and immediately gives off the
line from the middle of the clavicle to the recurrent laryngeal nerve (RLN), which loops behind
deltopectoral grove. the subclavian artery and ascends behind the
The subclavian vein is the continuation of the axillary vein common carotid artery into the tracheoesophageal
and originates at the level of the outer border of the first groove. On the left side, the vagus nerve travels
rib. It crosses in front of the anterior scalene muscle, between the common carotid and subclavian arteries
and at the medial border of the muscle it joins the internal and immediately gives rise to the RLN, which loops
jugular vein to form the innominate (brachiocephalic) around the aortic arch and ascends into the
vein. The left thoracic duct drains into the left subclavian tracheoesophageal groove.
vein at its junction with the left internal jugular vein. The
right thoracic duct drains into the junction of the right
subclavian vein and right internal jugular vein.
Internal jugular veins Fig. 9.5. Anatomical relationship between the

Left thoracic duct subclavian vein and the thoracic duct. The duct
Right thoracic duct drains at the posterior junction of the subclavian
vein with the internal jugular vein.
Right subclavian v.
Left subclavian v.
Right innominate v. Left innominate v.
71
Section 4: Neck
vein graft may be possible in some cases if the size

match is adequate.

The surgeon should have readily available a standard vascular
tray, sternal saw, Gigli saw, Finochietto retractor, periosteal
elevator, Doyen Raspatory, and a selection of Fogarty catheters.
Positioning
The patient is placed supine on the operating room table with
the ipsilateral arm abducted to 30 degrees. Avoid excessive
abduction. The patient’s head should be turned to the contra-
RLN
lateral side. Ensure that the patient is prepped from the chin to
RLN the knees and include the entire ipsilateral arm within the
Vagus n surgical field.
Incisions
Vagus n
Depending on the site of the subclavian vascular trauma
(left or right, proximal or distal) and on surgeon
preference, a variety of incisions and exposures can be
ITA used, the most common being the clavicular incision with
or without a median sternotomy, and the trap door
incision.
Generally, for injuries to the middle or lateral part of the
subclavian vessels, a clavicular incision provides good
exposure. For more proximal injuries, the clavicular
incision can be combined with a median sternotomy,
facilitating excellent exposure of both the left and right
subclavian arteries.
For proximal injuries on the left side, classically a “trap
door” incision has been described; however, it does not
improve surgical exposure and is associated with greater
postoperative morbidity.
Fig. 9.6. Anatomical relationship between the vagus and recurrent laryngeal In rare cases, if the injury is located at the mid or
nerves and the subclavian artery. The vagus nerve crosses over the first part of distal subclavian artery, exposure can be obtained
the subclavian artery, medial to the internal thoracic artery. On the left, the
recurrent nerve loops around the aortic arch and on the right, around the through a supraclavicular incision made directly over
subclavian artery. the site of injury. The proximal and distal exposures
are severely limited, however, and not generally
recommended.
General principles
Ligation of the subclavian artery is associated with Exposure through a clavicular incision
a high incidence of limb loss and should not be This is the preferred starting incision and provides good
performed. In critically unstable patients, temporary exposure of the second and third parts of the subclavian
shunting with delayed reconstruction should be artery. It begins at the sternoclavicular junction, extends
considered. over the medial half of the clavicle, and at the middle
Vascular reconstruction usually requires a 6 mm or portion of the clavicle it curves downward into the
8 mm polytetrafluoroethylene graft. A saphenous deltopectoral groove.
72
(a) (b)
Suprasternal notch
c
Deltopectoral groove
Fig. 9.7(a),(b). Patient positioning and clavicular incision for surgical exposure of the left subclavian artery. The head is turned to the opposite site and the arm
is abducted to 30 degrees. The clavicular incision begins at the sternoclavicular junction, extends over the medial half of the clavicle, and at the middle of the clavicle
it curves downward into the deltopectoral groove. The axillary vessels are deep to this groove.
Each of the muscles attached to the medial half of the detached with a combination of cautery, periosteal
clavicle (platysma and clavicular head of the elevator, and Doyen Rasp. The proximal half of the
sternocleidomastoid muscle superiorly, pectoralis clavicle is now exposed and stripped of all muscular
major and subclavius muscles inferiorly) are attachments.
(a)
Sternal head of SCM
Clavicular head of SCM
Clavicle
Fig. 9.8(a)–(e). Subclavian vascular exposure through a clavicular incision. All the muscles attached to the medial half of the clavicle (platysma and clavicular
head of the SCM superiorly, and pectoralis major and subclavius inferiorly, are divided, using cautery and the periosteal elevator. Note the deltopectoral groove,
deep to which are the axillary vessels.
73
Section 4: Neck
(b)

muscle
Deltopectoral groove
Sternal head of SCM
deep to which
muscle
are the axillary vessels
(c) (d)
Fig. 9.8(a)–(e). (cont.)
74
(e)
Subclavius
muscle
Fig. 9.8(a)–(e). (cont.)
The subclavian vessels lie deep to the clavicle, and their Excision of the medial half of the clavicle is also an
exposure requires the dislocation or division or excision of acceptable option. It does not result in any functional
the clavicle. disability but the cosmetic results are inferior to
The fastest approach is division of the clavicle with the clavicular reconstruction.
Gigli saw close to the sternoclavicular junction. At the end In clavicle-sparing procedures, the clavicle is
of the procedure, the anatomic integrity of the clavicle can grasped with a towel clamp and retracted upward
be restored by wiring together the divided ends. or downward to expose the underlying
Disarticulation of the sternoclavicular joint is another tissues.
option, but it takes significantly longer than division of
the clavicle.
(a) (b)
Fig. 9.9(a)–(d). The medial part of the clavicle has been freed from all muscle attachments. The clavicle is divided with a Gigli saw, close to the sternoclavicular
junction. The clavicle is retracted and the underlying tissues are exposed (circle). These fatty tissues need to be dissected in order to identify the vessels.
75
Section 4: Neck
(c) (d)
Gigli saw
Head of clavicle
Distal clavicle
Fig. 9.9(a)–(d). (cont.)
The subclavian vessels, especially the artery, lie deep under Exposure of the first and second part of the artery requires
the clavicular bed and their identification requires division of the strap muscles and the anterior scalene
extensive dissection of the surrounding tissues. The vein is muscle. The phrenic nerve, which lies anterior to the
located superficial and inferior to the artery and is the first anterior scalene muscle, should be identified and
vessel to come into view. The artery is significantly deeper preserved.
than most surgeons think.
(a) Fig. 9.10 (a)–(d). Exposure of the left subclavian

vessels after division and superior retraction of the
HEAD clavicle. The subclavian vein is in front of the anterior
scalene muscle and the artery behind it. Note the
phrenic nerve crossing over the muscle (a). The
anterior scalene muscle is divided to expose the
Retracted clavicle
proximal subclavian artery. The phrenic nerve is
retracted and protected (yellow loop) (b),(c).
Exposure of the subclavian vessels after division of
Internal jugular v. Anterior scalene m. the anterior scalene muscle (circles). TCT ¼
Subclavian a.
Phrenic n. thyrocervical trunk, ITA ¼ internal thoracic artery,
IJV ¼ internal jugular vein (d).
Subclavian v.
76
(b) Fig. 9.10 (a)–(d). (cont.)
Phrenic n
ARTERY
VEIN
(c)
Thyrocervical trunk
Vertebral a. Phrenic n.
Subclavian a.
Subclavian v.
Internal mammary a.
Identification of the artery may be difficult if there is no obtain proximal control of either a left or right subclavian
pulsation because of proximal injury, thrombosis, or artery injury.
retraction of the transected ends. In these cases, it is easier For very proximal control, the artery can be dissected
to expose the axillary artery first (see Chapter 10) and at its origin from the brachiocephalic artery on the right or
proceed proximally. from the aortic arch on the left. This can be done by
dissecting and lifting the thymic remnant and surrounding
fat in the upper mediastinum. This exposes the left
Exposure through a combined clavicular incision innominate vein and the aortic arch with its branches.
The origin of the subclavian artery (innominate artery on
and median sternotomy the right and aortic arch on the left side) is then identified
After successfully performing the clavicular exposure, a and isolated. This approach is described in detail in
standard median sternotomy should be performed to Chapter 16.
77
Section 4: Neck
(d) Fig. 9.10 (a)–(d). (cont.)
Clavicle retracted superiorly
Divided anterior
TCT scalene m
IJV
Subclavian a
ITA
Left innominate v
Subclavian v
Fig. 9.11. Combined clavicular and sternotomy incisions for exposure

of the very proximal subclavian artery.
78
(a) Fig. 9.12(a)–(c). Combined clavicular and
sternotomy incisions. The aortic arch with the
innominate artery, left common carotid artery, and
the left subclavian artery exposed. The left
innominate vein is seen retracted superiorly (a).
Left internal jugular vein Complete exposure of the left subclavian artery.
Left common carotid artery (IJV ¼ internal jugular vein, VA ¼ vertebral artery). (b).
Left subclavian vein
Exposure of the left proximal subclavian artery and
its major branches. Note the phrenic nerve, which is
Left innominate vein lateral to the internal thoracic artery and the vagus
nerve, which is medial (c).
Left subclavian artery
Innominate artery Aortic arch
(b)
IJV VA
Retracted clavicle
Left innominate vein
Proximal subclavian artery
Subclavian vein
Aortic arch
Divided sternum
(c)
Vertebral artery Thyrocervical trunk
Phrenic nerve
Vagus nerve
Left common carotid artery

Subclavian vein
Innominate vein
79
Section 4: Neck
Exposure through a supraclavicular incision The subcutaneous tissue above the clavicle is dissected to
expose and identify the subclavian vein, which courses
This incision is rarely used in trauma, because of the more superficial and inferior relative to the artery.
limited exposure and poor proximal and distal control it
The anterior scalene muscle is then divided 1 cm
provides. It may be considered in stable patients with distal
above its insertion onto the first rib. The vein is located in
subclavian arterial injuries.
front of the artery. Identify and preserve the phrenic nerve
A 6-cm transverse skin incision is made 1 cm above the located on the anterior surface of the muscle. The
medial half of the clavicle. The platysma is then divided. subclavian artery is then identified and isolated.
The clavicular head of the sternocleidomastoid muscle is
divided approximately 1 cm from its clavicular insertion.
Fig. 9.13. Supraclavicular incision for exposure of the subclavian artery.

A 6-cm transverse skin incision about 1 cm above the medial half of
the clavicle.
Fig. 9.14. Exposure of the right subclavian artery

Divided anterior scalene muscle through a supraclavicular incision. Division of the
Phrenic nerve anterior scalene muscle, with protection of the
phrenic nerve.
Subclavian artery Subclavian vein
80
Exposure through a “trap door” incision greater morbidity including bleeding, iatrogenic rib fractures,
severe postoperative pain and more common respiratory com-
This incision has been used by some surgeons to expose the
plications when compared to the above described clavicular/
proximal left subclavian artery. The “trap door” approach
median sternotomy approach.
combines a clavicular incision, an upper median sternotomy,
and an anterior left thoracotomy through the third or fourth
intercostal space. This exposure is, however, associated with Vascular reconstruction
Primary arterial repair is rarely possible. In the majority of
cases reconstruction using a synthetic or an autologous
saphenous vein graft is necessary. The choice of graft
(autologous or synthetic) is a matter of personal
preference, the general condition of the patient, and the
availability of an appropriately sized saphenous vein.
Standard vascular techniques are used.
The subclavian artery should not be ligated, even in
clinically unstable patients, because of the significant risk
of limb ischemia. For patients requiring damage control, a
temporary shunt with subsequent semi-elective definitive
reconstruction is recommended.
The subclavian vein can be ligated without any
significant complications. Repair should be considered
only if it can be done with simple techniques and
without producing significant stenosis. Stenosis greater
than 50% increases the risk of thrombosis and pulmonary
embolism.
At the completion of the operation, assess for a palpable
peripheral pulse and for any evidence of compartment
syndrome. On-table angiography should be considered in
cases with only a Doppler signal present. Routine
prophylactic fasciotomies are not necessary; however,
Fig. 9.15. Trap door incision combines a clavicular incision, upper median therapeutic fasciotomies should be performed
sternotomy, and a third or fourth intercostal space left thoracotomy. without delay.
Fig. 9.16. The divided clavicle is wired at the end

of the vascular procedure.
Reapproximated clavicle
Clavicle Subclavian artery
Subclavian vein
81
Section 4: Neck
Wound closure combined clavicular incision/median sternotomy, and

proceed distally.
The continuity of the divided clavicle can be re-established
with wiring or plating. In cases of disarticulation, the Postoperatively, monitor for peripheral pulses and for the
periosteum and ligaments around the sternoclavicular joint development of compartment syndrome.
are repaired. There is no role for routine prophylactic fasciotomy.
The platysma should be reapproximated separately for Administration of mannitol intraoperatively and
good cosmetic results. Failure to do so can result in postoperatively in hemodynamically stable patients
retraction of the muscle and poor aesthetics. may reduce the risk of developing compartment
syndrome.
Tips and pitfalls The phrenic nerve is at risk of transection during the division
of the anterior scalene muscle for proximal injuries. This will
The subclavian artery lies deep behind the clavicle and its result in paralysis of the ipsilateral diaphragm. Identify and
exposure can be challenging. Its proximal segment is approxi- protect it prior to the division of the muscle.
mately 5–6 cm from the skin and extensive dissection of the During dissection of the right subclavian artery, isolate and
surrounding pre-scalene muscle fat is required. preserve the recurrent laryngeal nerve, which loops around the
Intraoperative use of ultrasound may be helpful to identify proximal subclavian artery anteriorly prior to ascending (pos-
the artery. teriorly) into the neck.
In the absence of pulsation (thrombosis or complete During dissection of the subclavian vein near its junction
transection), start with the much easier exposure of the with the internal jugular vein, protect the thoracic duct, which
axillary artery and proceed proximally towards the injury. drains into this part of the vein. If injured, ligate both ends.
For very proximal injuries, start with the isolation Failure to recognize and ligate the injured duct results in a
of the origin of the subclavian artery, through the troublesome postoperative chyle leak.
82
Section 4 Neck
Axillary vessels
Chapter
10 Demetrios Demetriades and Emilie Joos
Surgical anatomy surrounded by the cords of the brachial plexus, and gives
External landmarks: the axillary vessels start at the two branches. The third part lies lateral to the muscle, is
middle of the clavicle, course deep, under the surrounded by the nerves of the brachial plexus, and gives
deltopectoral groove and end at the lateral border of three branches.
the axilla. The axillary vein is the continuation of the basilic vein.
The axillary artery is divided by the pectoralis minor into Prior to its transition to the subclavian vein, the cephalic
three parts: the first part is proximal to the muscle and vein joins it. Its middle segment lies under the pectoralis
gives one branch. The second part is under the muscle, is minor muscle, inferior to the axillary artery.
Clavicle Fig. 10.1. The axillary vessels start under the

middle of the clavicle and curve downwards,
Subclavius m deep under the deltopectoral groove. Part of the
Cephalic v vessels are under the pectoralis minor muscle. The
vein is below and more superficial to the artery.
Note the cephalic vein crossing over the pectoralis
Divided minor muscle and draining into the proximal
pectoralis minor m axillary vein.
Divided
pectoralis major m
Axillary v
Axillary art
83
Section 4: Neck
General principles (b)
Ligation of the axillary artery is associated with a high

incidence of limb loss and should not be performed. In
critically unstable patients, temporary shunting with Head
delayed reconstruction should be considered.
Vascular reconstruction can be done with either a
saphenous vein graft or a synthetic graft.
le
vic
Cla
Special surgical instruments Left arm
A standard vascular tray.
Periosteal elevators and Doyen Raspatory may be needed
for clavicular resection and exposure of the distal
subclavian vessels (see Chapter 9).
Positioning
The patient should be in the supine position, with the Fig. 10.2(a),(b). (cont.)
injured arm abducted from the body at about 30 degrees.
The head is slightly turned to the opposite side.
The neck, arm, and entire chest should be fully prepped.
The groin should be included in the surgical field in case a
Vascular exposure
vein harvest is needed. The subcutaneous tissue under the incision is dissected into
the deltopectoral groove. The cephalic vein will come into
view and can be retracted or ligated.
Incision The lower skin flap is mobilized to allow good exposure of
The incision starts just below the middle of the clavicle, and the pectoralis major and its insertion into the humerus.
courses over the deltopectoral groove. The pectoralis major muscle fibers are split and retracted,
In very proximal injuries the incision should start at the exposing the underlying pectoralis minor muscle. However,
sternoclavicular junction, course directly over the medial in severe active bleeding or if the exposure is not satisfactory,
half of the clavicle and, at the middle of the clavicle, curve the pectoralis major is divided about 2–3 cm from its
downward into the deltopectoral groove. The clavicle may insertion into the humerus and retracted medially. The
have to be divided to allow proximal vascular control (see underlying pectoralis minor muscle comes into full view.
Chapter 9).
(a)
(a)
Head
Head
Left shoulder
le
vic Pectoralis
Cla Left arm
major
Fig. 10.3(a),(b). The lower skin flap is mobilized to allow good exposure of
Fig. 10.2(a),(b). The standard incision for the exposure of the axillary vessels the pectoralis major and its insertion into the humerus (circle). The muscle
starts just below the middle of the clavicle, and courses over the deltopectoral might be split to expose the underlying pectoralis minor. However, for faster
groove. The cephalic vein courses superficially in the groove and should be and better exposure its insertion into the humerus may be divided 2–3 cm from
avoided. the bone.
84
Chapter 10. Axillary vessels
(b) (b)
Head Retracted pectoralis

major
Left arm
Pectoralis minor
Fig. 10.3(a),(b). (cont.) Fig. 10.4(b). Retraction of the divided pectoralis major exposes the
underlying pectoralis minor and the distal subclavian vessels and brachial
plexus. Note the roots of the brachial plexus (artery in red vessel loop, vein in
blue, and nerves in yellow). The middle part of the axillary vessels are
The pectoralis minor is then retracted laterally or divided underneath the pectoralis minor muscle.
near its insertion into the coracoid process and retracted
medially.
The vein will first come into view, inferior and anterior to
the artery. (a)
The axillary vessels are now fully exposed, with the brachial
plexus roots and nerves surrounding them.
(a)
Left shoulder
Head
Left arm
Pectoralis
minor
Retracted pectoralis
major
Left arm
Fig. 10.5(a). Division of the pectotalis minor exposes the middle part of the
subclavian vessels.
Divided and retracted
pectoralis major
Fig. 10.4(a). Heavy absorbable sutures are placed on the divided edges of the
pectoralis major. The edges are retracted to expose the underlying pectoralis
minor muscle. At the completion of the operation, the sutures are tied together
to reconstruct the muscle.
85
Section 4: Neck
(b)
Left Left
shoulder shoulder
Divided
pectoralis minor
Fig. 10.7. Damage control with temporary shunt (arrow). The sutures securing
Fig. 10.5(b). After division of the pectoralis minor muscle, the axillary vessels the tube proximally and distally are tied together to prevent accidental
are completely exposed (artery in red vessel loop, vein in blue, and nerves in dislodgement (vein in blue loop and nerves in yellow).
yellow).
Vascular injury management Closure

The axillary artery should always be repaired or Reconstruction of the pectoralis minor is likewise
reconstructed. Damage control with temporary shunting performed.
and delayed reconstruction should be considered in
patients in extremis.
The arterial reconstruction can be done with either a
synthetic or an autologus saphenous vein graft. Head Left shoulder
The axillary vein should be repaired only if it can be done
with simple suturing. Complex graft reconstruction is not
advisable. Ligation of the vein is well tolerated.
The divided pectoralis major muscle should be
reapproximated using absorbable sutures.
Left arm
Left
shoulder
v icle
Cla Fig. 10.8. Reconstruction of the pectoralis major muscle.
Tips and pitfalls

Positioning: Excessive abduction of the arm distorts
the anatomy and makes the exposure more
difficult.
To obtain proximal control of the subclavian
Fig. 10.6. The injured part of the axillary artery is debrided to healthy tissues
(circles). Reconstruction usually requires a synthetic size 6 or 8 graft (vein in blue, artery, resection of the proximal clavicle may
vessel loop and nerves in yellow). be required.
86
Chapter 10. Axillary vessels
If there is ongoing bleeding and rapid exposure is needed, In cases where there was prolonged ischemia due to an
the pectoralis major and minor muscles should be divided, arterial injury, monitor closely for compartment syndrome.
as described above. There is no need for routine prophylactic arm fasciotomy.
Care must be taken not to injure the brachial plexus, which Intraoperative administration of mannitol in stable patients
is intimately associated with the axillary vessels. may reduce the risk of compartment syndrome.
87
Section 4 Neck
Vertebral artery injuries

Chapter
11 Demetrios Demetriades and Nicholas Nash
Surgical anatomy
The vertebral artery (VA) is the first cephalad branch of
the subclavian artery. From the trauma surgery perspective,
it is divided into three parts: Part I, from its origin at the
subclavian artery to C6, where it enters the vertebral
foramen; Part II, which courses in the vertebral bony canal,
C2
formed by the transverse foramen, from C6 to C1; Part III,
which runs outside the vertebral canal, from C1 to the base
of the skull. The VA enters the skull through the foramen
magnum, piercing the dura mater. It joins the opposite VA
to form the basilar artery, which is part of the circle of Willis.
The first part of the VA courses superiorly and posteriorly
between the anterior scalenus and the longus colli muscles,
before entering the vertebral canal at the C6 level.
The carotid sheath is anterior and medial to the first part of
the VA. C6
The first part of the VA is located in the triangle formed by
the sternal and clavicular insertions of the
sternocleidomastoid muscle and the clavicle.
The external landmark of C6, where the VA enters into the
vertebral canal, is the cricoid cartilage.
The VA is surrounded by a venous plexus.
General principles
Many vertebral artery (VA) injuries can be effectively
managed with angioembolization. Due to the difficult
anatomy and complex operative exposure, angiographic
intervention remains the preferred therapeutic modality.
Operative management and direct surgical control of the
bleeding are reserved only for cases with severe active Fig. 11.1. The vertebral artery (VA) is the first cephalad branch of the
bleeding or if interventional radiology is not available. subclavian artery. It enters the vertebral canal at the C6 level and exits the canal
at the C2 level.
Ligation or endovascular occlusion of the VA is tolerated
well and rarely causes neurological deficits.
Gunshot wounds to the VA are often associated with spinal
fractures and spinal cord injuries.
88
Chapter 11. Vertebral artery injuries
Special surgical instruments Exposure

Equipment for the operation should include a major Continue the dissection deep into the base of the triangle. Place
vascular tray for trauma, periosteal elevator, and bone a self-retaining retractor in the wound, retracting the sternal
rongeurs. head of the SCM muscle medially and the clavicular head
laterally. If necessary, divide the clavicular head of the SCM
muscle near the clavicle or split the muscle heads superiorly.
Positioning The scalene fat pad is then visualized and dissected to
Supine with head turned away from the injured side and if expose the anterior scalene muscle. The phrenic nerve will
the cervical spine has been cleared, the neck should be be running on the surface of the anterior scalene and the
slightly extended, with a folded towel placed between the inferior thyroid artery. The muscle is retracted laterally or
patient’s shoulders. divided.
The carotid sheath is the first vascular structure to be
identified in the medial part of the triangle. The jugular
Exposure of the first part of the VA vein is lateral, the common carotid artery medial, and the
vagus nerve posterior. The structures of the carotid sheath
Incision are dissected and retracted medially. The first part of the
A supraclavicular transverse incision may be used in rare VA is located deeper and more laterally, between the
occasions for exposure of the proximal VA, outside the anterior scalenus laterally and longus colli muscle medially.
vertebral canal. This is a limited exposure and does not Identification of the vessel is greatly facilitated by
allow satisfactory exploration of the carotid sheath or the palpating, with the tip of the index finger, the groove
aerodigestive tracts. between the vertebral body of C7 and the transverse
Mark the sternal and clavicular heads of the process. The VA lies immediately anterior to this groove.
sternocleidomastoid (SCM) muscle. Perform a transverse A right-angled clamp is used to dissect the VA. Care should
skin incision, extending between the medial border of the be taken not to injure the vertebral venous plexus, which is
sternal head and the lateral border of the clavicular head of located in front of the artery.
the SCM muscle, approximately two finger breadths above The phrenic nerve is seen laterally, on the surface of the
the clavicle. anterior scalenus muscle, and should be protected.
Fig. 11.2(a)–(c). Exposure of the first part of the

(a)
right VA through a supraclavicular transverse incision.
The incision extends between the medial border of
the sternal head and the lateral border of the
clavicular head of the SCM muscle, about two finger
breadths above the clavicle. Following the division of
the platysma, the sternal and clavicular heads of
the SCM muscle are exposed. The clavicular head
of the SCM can be divided and retracted superiorly
for better exposure.
SCM muscle
Incision Sternal head of SCM
Right clavicle
89
Section 4: Neck
(b) Fig. 11.2(a)–(c). (cont.)
Platysma
Clavicle
(c)
Clavicular head
SCM
Sternal head
SCM
Right clavicle
90
The incision is placed over the anterior border of the SCM

Right ear Chin muscle, extending from just below the mastoid process to
the suprasternal notch.
Exposure
Scalene fat pad Internal jugular The dissection is continued through the subcutaneous
tissues and platysma, until the anterior border of the SCM
vein
is encountered. The SCM is retracted laterally to expose the
carotid sheath. The jugular vein is more superficial and
lateral, the common carotid artery medial, and the vagus
nerve will lie posterior.
The contents of the carotid sheath are all identified
and retracted medially. The midline structures of the
neck, which include the esophagus, trachea, and larynx,
may also be encountered during this portion of the
Right clavicle
dissection and should be gently retracted medially as
necessary.
The anterior scalene muscle is retracted laterally or
divided while protecting the phrenic nerve which lies on
Fig. 11.3. The internal jugular vein with the carotid sheath is retracted the surface of the muscle. The longus colli muscle,
medially and the scalene fat pad is exposed. Dissection in this area exposes the
anterior scalene muscle, which is retracted laterally or divided (protect the which is on the anterolateral surface of the vertebra,
phrenic nerve crossing over the anterior scalene). and the prevertebral fascia, are swept off the bone with
a periosteal elevator, exposing the anterior rim of the
vertebral foramen. The rim is located between the
vertebral body and the anterior tubercle of the
transverse process and is best identified by palpation
with the tip of the index finger. This rim is excised
Vertebral (a)
artery
Chin Left ear

Carotid sheath
Clavicle
Fig. 11.4. Exposure of the first part of the VA, prior to its entry into the
vertebral canal. The anterior scalene muscle along with the phrenic nerve have
been retracted laterally and the VA is exposed just deep to it.
Suprasternal notch
Sternocleidomastoid incision approach
Incision Fig. 11.5(a)–(c). Exposure of the left VA in the vertebral canal through an
SCM incision. An incision is made along the anterior border of the SCM, and
This is the preferred incision in trauma. It allows exploration extends from below the mastoid process to the suprasternal notch (arrow) (a),
of the carotid artery, the internal jugular vein, the (b). (b) The anterior border of the SCM is mobilized and SCM is retracted laterally
aerodigestive tract, and the first and second parts of the VA. to expose the carotid sheath (c).
91
Section 4: Neck
(b) with bone rongeurs, and the VA is exposed and

ligated or clipped. If necessary, the same process is
repeated at the adjacent vertebrae. The anterior nerve
root is posterior to the VA and not at risk of injury
if the unroofing is done properly. Troublesome
bleeding from the surrounding venous plexus can
be controlled with local hemostatic agents and
compression.
Suprasternal notch
Left carotid sheath
Anterior rim of the

vertebral canal
Head
Longus colli m.
Anterior border of
SCM
(c) Fig. 11.6. The carotid sheath structures have been retracted medially. The
forceps and arrow are pointing to the anterior rim of the vertebral foramen, that
has already been cleared of its longus colli muscle attachments with a periosteal
elevator. The vertebral artery lies in the canal, directly below this bony rim.
Left carotid art
Left internal
jugular vein (a)
Longus colli muscle
Unroofed vertebral
canal
Anterior tubercle
Nerve root
Vertebral foramen
with VA
Left vagus nerve
Fig. 11.7(a),(b). The longus colli muscle is detached and retracted. With
the help of bone rongeurs, the vertebral canal is unroofed by excising the
anterior rim to expose the VA. The rim can easily be palpated with the tip of the
finger, and is located between the body of the vertebra and the anterior
tubercle of the transverse process (a). The vertebral canal is unroofed (arrows)
and the VA is exposed (b).
92 Fig. 11.5(a)–(c). (cont.)

(b) Tips and pitfalls

In stable patients angioembolization is the procedure of
choice.
The anatomy of the VA is difficult and the surgeon should
consult an atlas before the operation.
Proximal ligation of the VA does not effectively control
bleeding from a distal injury because of retrograde
blood flow.
For distal VA injuries, above C2, the exposure is difficult
and a suboccipital craniectomy by a neurosurgical team
may be necessary.
For penetrating injuries that require emergent exploration
VA due to bleeding, if direct visualization and ligation of the
VA is not possible, damage control packing of the area with
local hemostatic agents with postoperative
angioembolization is a viable option.
Fig. 11.7(a),(b). (cont.)
(a) (b)
IJV
CCA
VA
Vagus n
Fig. 11.8(a),(b). Following unroofing of the vertebral canal (circle), the VA (red vessel loop) is exposed. (CCA ¼ common carotid artery, IJV ¼ internal jugular
vein, VA ¼ vertebral artery.) Arrows in Fig. 11.8(b) show the edges of the unroofed canal. Note the carotid sheath contents retracted medially (yellow vessel loop is
around the vagus nerve).
93
Section 4 Neck
Trachea and larynx

Chapter
12 Elizabeth R. Benjamin and Kenji Inaba
Anatomy The paired strap muscles lie in front of the trachea and
larynx. These include superficially the sternohyoid muscles
The trachea is 10–12 cm long and 2–2.5 cm wide, and the underlying sternothyroid and thyrohyoid muscles.
extending from C6 to T5.
The thyroid cartilage is suspended from the hyoid bone by
The trachea is composed of 16–20 incomplete rings with a
the thyrohyoid membrane. The cricothyroid ligament
flattened posterior wall of muscle and fibrous tissue.
connects the inferior portion of the thyroid cartilage to the
The anatomic borders of the trachea include the cricoid cartilage. Inferior to this is the first tracheal ring.
isthmus of the thyroid and paired strap muscles
The larynx is composed of three paired (arytenoid,
anteriorly, the common carotid arteries, thyroid lobes,
corniculate, and cuneiform), and three unpaired (cricoid,
and recurrent laryngeal nerves laterally and the esophagus
thyroid, and epiglottic) cartilages.
posteriorly.
(b)
(a)
Thyroid
HEAD
Pharyngoesophageal
junction
a
he us
rac hag
e
T Es
op
Spin
Posterior
membranous
trachea
Sternocleidomastoid
Recurrent laryngeal nerve
Fig. 12.1(b). Lateral view of the midline neck structures from a left
sternocleidomastoid incision. The trachea is the most anterior structure. The
posterior membranous portion of the trachea abuts the anterior surface of the
Fig. 12.1(a). The trachea is composed of 16–20 incomplete rings. The esophagus and the recurrent laryngeal nerve runs in the trachea–esophageal
posterior membranous portion of the trachea lies just anterior to the groove. Posterior to the esophagus is the spine. The carotid sheath and
esophagus. sternocleidomastoid muscle are retracted laterally to provide this exposure.
94
Chapter 12. Trachea and larynx
(c) Patient positioning

In a patient with isolated injury and a cleared cervical
spine, it is ideal to place a bump or shoulder roll
underneath the upper back and allow the patient’s
head to extend, thus opening up the neck for improved
Vagus nerve
exposure.
If there is concern for cervical spine injury, the patient
must be kept in spinal precautions and no shoulder roll
Recurrent laryngeal should be used. Cervical spine stabilization can be
nerves (RLN) accomplished using bilateral sandbags.
Carotid artery
Subclavian artery
Aortic arch
Fig. 12.1(c). The recurrent laryngeal nerves (RLN) run laterally along the
trachea–esophageal groove.
Fig. 12.2. A bump is placed between the patient’s shoulder blades to allow
General principles hyperextension of the neck and improved exposure of the underlying structures.
Stridor, respiratory distress, blowing neck wound,

hemoptysis, and subcutaneous emphysema are all signs
and symptoms of a tracheolaryngeal injury. Patients with
hard signs of injury which include hemoptysis, air Incisions
bubbling, and respiratory distress can proceed directly to The choice of incision depends on the mechanism of injury
the operating room. CT is an excellent screening test. (blunt or penetrating), the location of the injury, and the
Direct laryngoscopy can be used to confirm laryngeal injury, suspected presence of associated injuries (i.e., esophagus or
and bronchoscopy can be used to identify tracheal injury. major vessel).
In the presence of tracheal trauma, there is a high incidence
of associated injury including vascular injury.
In suspected airway injury, a definitive secure airway
Collar incision
obtained by an expert anesthesiology team should be the For tracheal injuries, a collar incision is made
highest priority. This is best achieved in the operating approximately two finger breadths above the sternal notch,
room with the surgical team ready to intervene. If the extending to the medial borders of the sternocleidomastoid
patient is maintaining an airway, do not attempt muscles.
prophylactic intubation in the emergency department. After the collar skin incision is made, the platysma is
divided, and subplatysmal flaps are created superiorly and
inferiorly to expose the strap muscles.
The strap muscles are split in the avascular plane along the
Instruments midline to expose the trachea, larynx, and thyroid gland.
A standard instrument tray can be used for tracheal and The thyroid isthmus will often need to be divided in order
laryngeal dissection. Weitlaner or cerebellar retractors and to fully expose the underlying trachea and larynx. This can
a tracheal hook are helpful for exposure, especially in the be accomplished using electrocautery or suture ligation.
deep neck. The larynx may also be accessed from the collar incision,
A size 6 and 8 tracheostomy tube should be available in the provided a generous superior extension of the subplatysmal
event of a large tracheal injury or lost airway. flap is performed.
95
Section 4: Neck
(a) (b)
(c)
Fig. 12.3. A curvilinear incision is made two finger breadths above the sternal
notch and extending laterally to the sternocleidomastoid muscles (a), (b). This
incision is carried through the platysma (c).
Fig. 12.4. Subplatysmal flaps are dissected

superiorly and inferiorly to expose the underlying
strap muscles.
Platysmal flap
SCM
Strap muscles
Trachea
96
(a) (b)
HEAD
Sternohyoid m
Strap muscles
Thyroid isthmus
Fig. 12.5(a),(b). The paired strap muscles are split at the midline to expose the trachea, larynx, and thyroid. The most superficial strap muscle encountered is the
sternohyoid muscle.
(a) (c)
HEAD
Thyroid
cartilage
Trachea
Thyroid isthmus
Divided isthmus
Fig. 12.6(a). The thyroid gland overlies the trachea and might interfere with Fig. 12.6(c). Exposure of the trachea after division of the isthmus of the
adequate exposure of the underlying trachea. thyroid.
(b)
Sternocleidomastoid incision
In patients with suspected associated injuries to the
esophagus or major vessels, an incision over the anterior
border of the sternocleidomastoid is preferable (see
Chapter 7).
A neck incision is made through the skin and the platysma
is divided.
The sternocleidomastoid muscle is retracted laterally to
Division of the omohyoid muscle allows for exposure of
the deep structures of the neck.
The carotid sheath is then retracted laterally with the
sternocleidomastoid muscle to expose the trachea and
Fig. 12.6(b). Division of the thyroid isthmus for better exposure of the trachea. esophagus.
97
Section 4: Neck
(a) (a)
Innominate a
Carotid a Divided
Divided
sternum
Trachea sternum Trachea
Median
sternotomy
Brachiocephalic v
Aortic arch (divided)
Left brachiocephalic v
Fig. 12.8(a). The addition of a sternotomy and division of the brachiocephalic

vein provide excellent exposure to lower tracheal injuries. The aortic arch and
brachiocephalic artery can be gently retracted to access the lower trachea.
(b)
Fig. 12.7(a). Exposure of the lower trachea requires addition of a median

sternotomy. The left brachiocephalic vein may need to be divided to provide
additional exposure.
Divided
sternum
Divided
(b) sternum
Aortic arch
Innominate a
Fig. 12.8(b). Repair of simple penetrating wound (circle) to the lower trachea,
through a combined collar incision and median sternotomy.
Bilateral sternocleidomastoid incisions may be necessary

for penetrating transcervical wounds.
For lower tracheal injuries, a median sternotomy may be
Left brachiocephalic v necessary. This will usually be an inferior extension of the
sternocleidomastoid or collar incision.
A midline incision is made from the sternal notch to the
xiphoid process.
The midpoint of the sternum is identified and scored using
electrocautery.
Superiorly, the interclavicular ligament is divided and the
Fig. 12.7(b). Ligation and division of the left brachiocephalic vein. undersurface of the sternum is bluntly dissected away from
the pericardial sac.
98
The sternum is divided using an electric saw or Lebsche Prior to placing sutures through the trachea, it is important
knife, providing exposure to the substernal trachea. to deflate the endotracheal balloon in order to avoid
For inferior tracheal injuries, rarely the damage or inclusion of the balloon in the repair.
brachiocephalic vein may need to be divided for In rare cases, when the injury is not amenable to primary
additional exposure. repair, a tracheal resection and anastamosis is performed.
If resection is to be performed, the trachea is mobilized
superiorly and inferiorly using sharp dissection to
Repair minimize potential recurrent laryngeal nerve injury.
The injured section of trachea is sharply debrided.
Most penetrating laryngotracheal injuries without
The trachea is reapproximated using interrupted 3–0
significant tissue loss can safely be managed by primary
absorbable sutures.
repair and without a tracheostomy.
The endotracheal tube cuff is advanced and inflated
All devitalized tissue must be debrided prior to repair or distal to the repair or, in the event of a complex repair, a
reconstruction.
tracheostomy may be performed.
Most injuries to the cervical trachea can be primarily
All efforts should be made for early postoperative
repaired using simple interrupted absorbable suture.
extubation.
In complex injuries, the repair should be buttressed with an
adjacent muscle flap. A protective tracheostomy should be
considered.
(b)
(a)
HEAD
HEAD
Strap muscle
flap
Strap muscle
flap
Fig. 12.9(a). Buttressing of the tracheal repair (circle) with muscle flap:
preparation of strap muscle flap. Fig. 12.9(b). Strap muscle flap sutured over the tracheal repair.
99
Section 4: Neck
(c) In extensive injuries with large mucosal lacerations,

displaced fractures, unstable laryngeal cartilaginous
skeleton, or complete laryngotracheal separation, a head
and neck surgical team should be involved. Many of
HEAD these patients may require endolaryngeal stents or other
complex repairs.
Tips and pitfalls

Once the platysma is divided, care must be taken to avoid
or ligate the paired anterior jugular veins to avoid excess
blood loss or staining of the operative field.
A septum exists along the midline between the anterior
strap muscles that identifies the avascular plane. Failure to
identify this anatomic marker can lead to additional blood
loss and damage to the muscle that may be needed later to
buttress a repair.
The recurrent laryngeal nerve runs vertically on
either side of the trachea along the tracheoesophageal
groove. Injury to this nerve is more common with the
local use of electrocautery or if the dissection planes
are unclear.
During mobilization of the trachea, it is important to
minimize the superior and inferior extent of dissection in
order to preserve tracheal blood supply.
In most major laryngotracheal injuries, the patient
aspirates significant amounts of blood. It is strongly
recommended that fiberoptic bronchoscopy be
performed to clear the bronchial tree at the end of
Fig. 12.9(c). Protective tracheostomy in addition to muscle flap buttressing. the operation.
Fig. 12.10. In most major laryngotracheal injuries,

the patient aspirates significant amounts of blood.
It is strongly recommended that suctioning and
fiberoptic bronchoscopy are performed to clear the
bronchial tree at the end of the operation.
100
Section 4 Neck
Cervical esophagus
Chapter
13 Elizabeth R. Benjamin and Kenji Inaba
Surgical anatomy any of these structures must always include evaluation of

the cervical esophagus.
The cervical esophagus extends from the cricopharyngeus
Early clinical signs and symptoms of cervical esophageal
muscle into the chest to become the thoracic esophagus.
injury include odynophagia, hoarseness, hematemesis, and
The external landmark of the pharyngoesophageal junction
subcutaneous air. Late signs include fever, erythema,
is the cricoid cartilage. On esophagoscopy, this is at 15 cm
leukocytosis, swelling and/or abscess formation, and
from the upper incisors.
ultimately spreading of the infection along the precervical
The esophagus lacks a serosal layer and consists of an outer plane leading to mediastinitis.
longitudinal and inner circular muscle layer.
Workup of a stable patient with potential esophageal
The cervical esophagus is approximately 5–7 cm long and injury includes a neck CT, gastrograffin followed by
lies posterior to the cricoid cartilage and trachea and barium swallow study, and/or esophagoscopy. CT
anterior to the longus colli muscles and vertebral bodies. It is an excellent screening examination, however, it
is flanked by the thyroid gland and carotid sheath on often requires direct confirmation with a swallow or
either side. esophagoscopy.
Blood supply is primarily from the inferior thyroid artery, Management of esophageal injuries hinges on early
although significant collateral circulation exists. debridement and repair or, if delayed, drainage, broad
The recurrent laryngeal nerves lie on either side of the spectrum antibiotics, and nutritional support.
esophagus in the tracheoesophageal groove.
Cricopharyngeus
Thyroid
muscle Special instruments
HEAD
In addition to a standard instrument tray, for the neck
exploration, a self-retaining Weitlaner or cerebellar
a
he us retractor will be necessary.
ac ag
Tr h
op ne If there is concern for thoracic extension of the esophageal
Es Spi
injury, the surgeon should be prepared to perform a high
right thoracotomy to expose the proximal thoracic
esophagus.
SCM A rigid and flexible endoscope should be available for
RLN intraoperative esophagoscopy if necessary.
Fig. 13.1. Surgical anatomy of the cervical esophagus. RLN, recurrent

laryngeal nerve.
Patient positioning
Provided cervical spine injury has been ruled out,
the patient is positioned in a supine position with the
General principles head turned to the right. A bump is placed under
Esophageal trauma often presents with other associated the patient’s shoulder to allow gentle neck extension
injuries including carotid, jugular, tracheal, and thyroid for improved exposure. When possible, the arms are
injury. As such, neck exploration for suspected injury of tucked.
101
Section 4: Neck
Incision
Standard exposure of the cervical esophagus is
Sternohyoid Omohyoid SCM
through a left-sided oblique neck incision running
along the anterior border of the sternocleidomastoid
muscle and extending from the mastoid to the
suprasternal notch.
Fig. 13.4. The sternocleidomastoid muscle (SCM) runs tangentially across the
neck and must be retracted laterally to expose the vascular and aerodigestive
structures of the neck. The omohyoid and sternohyoid muscles are medial and
just deep to the SCM.
Fig. 13.2. To access the cervical esophagus, the patient’s head is turned to the
right and the neck is extended. The incision is made along the anterior border Omohyoid
of the sternocleidomastoid muscle.
Esophageal exposure
An incision is made through the skin and dermis and the
platysma is divided.
The sternocleidomastoid muscle is retracted laterally to
Division of the omohyoid muscle allows for exposure of
the deep structures of the neck.
Fig. 13.5. The omohyoid is isolated and divided in order to expose the deep
structures of the neck.
Platysma The carotid sheath is then retracted laterally, while the

trachea and thyroid are retracted medially to expose the
cervical esophagus.
A nasogastric tube, if in place, can be of assistance in
palpating the esophagus.
The middle thyroid vein and often the inferior thyroid
artery may be ligated and divided to gain better access to
the esophagus.
Retraction alone may provide adequate exposure for
injury identification and repair. If further mobilization is
required, with the aid of a nasogastric tube or bougie,
the esophagus can be bluntly dissected circumferentially
and manipulated by passing a ½ inch Penrose drain
Fig. 13.3. The platysma muscle is divided using sharp dissection or
electrocautery. This layer is reapproximated with absorbable suture upon or vessel loop around the structure for additional
closure. retraction.
102
Chapter 13. Cervical esophagus
Thyroid
Cut edge omohyoid Repair
Traumatic cervical esophageal injury can often be
identified on gross inspection. Intraoperative endoscopy
or esophageal insufflation with air or methylene blue
can also be useful adjuncts to identify an injury.
Esophagus
Trachea The majority of injuries can be repaired primarily
Spine without tension. The wound edges are first debrided
of any devitalized tissue and the mucosal defect
is identified. The injury can be closed in one or two
RLN layers however, when possible, a two-layer closure
using absorbable suture is recommended.
The inner layer should reapproximate mucosal
edges.
Neighboring strap muscle can be used to buttress the
Fig. 13.6. The thyroid is anterior on the trachea and can be retracted medially. esophageal repair and isolate the suture line from
With the omohyoid divided, the tracheal–esophageal groove is exposed. The
recurrent laryngeal nerve (RLN) runs in this groove, anterior to the cervical
associated tracheal or vascular injuries.
esophagus. From this exposure, the esophagus is directly posterior and left A closed suction drain is typically placed outside
lateral to the trachea and anterior to the spine. the esophageal repair. This drain is removed on
POD #5–7 after anastamotic leak is ruled out by
contrast study.
(a) (b)
HEAD
Trachea
RLN
Esophagus
Fig. 13.7(a),(b). Additional exposure can be obtained by mobilization and gentle retraction of the esophagus.
103
Section 4: Neck
(a) (b)
HEAD
HEAD
a
che
Tra
Trachea
Fig. 13.8(a),(b). A full thickness defect of the left lateral wall of the cervical esophagus (circle).
For destructive injuries that are unable to be

primarily repaired, wide drainage, possible cervical
esophagostomy, and delayed interposition graft are
treatment options.
In some cases, local resection with one- or two-layer
anastomosis may be necessary.
In rare occasions with destructive injuries and
damage control, a proximal esophagostomy with distal
stapling may be necessary. Semi-elective reconstruction
with gastric pull-up or colon bypass may be done at a
later stage.
Fig. 13.9. Esophageal injuries are repaired with absorbable suture in one or
two layers. Repair must include reapproximation of the mucosa.
(a) (b)
Mobilized strap HEAD Mobilized strap

muscle muscle
Fig. 13.10(a). Neighboring strap muscle can be mobilized to provide a Fig. 13.10(b). Mobilized strap muscle placed over esophageal
buttress or be used to isolate the esophageal repair. repair (circle).
104
Chapter 13. Cervical esophagus
Tips and pitfalls Care must be taken with the outer layer not to
cause narrowing of the esophagus. It is often helpful
The recurrent laryngeal nerve runs in the
to close these injuries over a nasogastric tube
tracheoesophageal groove and can easily be injured during
or bougie.
exposure of the esophagus.
Care should be taken to avoid missing a second esophageal
The posterior membranous portion of the trachea is
injury on the opposite site. Check carefully with
very delicate, and injury can easily occur with dissection
appropriate circumferential mobilization of the esophagus
of the trachea off the anterior esophagus.
or on table endoscopy.
The inner layer of the esophageal repair must reapproximate
the mucosal edges to minimize the rate of postoperative leak.
105
Section 5 Chest
General principles of chest trauma operations

Chapter
14 Demetrios Demetriades and Rondi Gelbard
Surgical anatomy
The following are the major muscles that will be encountered
and may be divided during thoracic operations for trauma:
Anterior chest wall Trapezius muscle

Pectoralis major muscle. It originates from the anterior surface of
the medial half of the clavicle, the anterior surface of the sternum,
and the cartilages of all the true ribs. The 5 cm wide tendon inserts
into the upper humerus.
Latissimus dorsi muscle
Pectoralis minor muscle. It arises from the third, fourth, and fifth ribs,
near their cartilages, and from the aponeuroses over the intercostal
muscles. It inserts into the coracoid process of the scapula.
Lateral chest wall

Serratus anterior muscle. It originates from the lateral part of the first
eight to nine ribs and inserts into the medial aspect of the scapula. Fig. 14.2. The latissimus dorsi m is the main muscle encountered and divided
during a posterolateral incision.
Posterior chest wall

Latissimus dorsi muscle. It originates from the spinous processes of
the lower thoracic spine and the posterior iliac crest and inserts
into the upper portion of the humerus.
General technical principles

Excised pectoralis major m In order to preserve chest wall function, muscle sparing
techniques should be utilized whenever possible.
Excessive rib retraction should be avoided to prevent
rib fractures, and all ribs should be preserved when
possible.
The thoracic wall structures should be closed by re-
Pectoralis minor m approximating the divided muscles in multiple layers.
Avoid over-approximating the ribs in order to reduce
Anterior serratus m postoperative pain.
Anterolateral thoracotomy
Incision Preoperative placement of a double-lumen endotracheal
Pectoralis major m tube or a bronchial blocker allows isolation of the
ipsilateral lung and facilitates the exposure of posterior
Fig. 14.1. The pectoralis major and pectoralis minor muscles in the anterior
chest wall and the anterior serratus muscle on the lateral thoracic wall may be mediastinal structures, such as the descending thoracic
divided during anterolateral thoracotomy. aorta and the esophagus.
107
Section 5: Chest
Positioning Median sternotomy

In hemodynamically unstable patients, often there is no time This is the preferred incision in penetrating injuries to the
for special positioning and the patient is placed in the standard anterior chest.
supine position. It provides good exposure of the heart, the anterior
mediastinal vessels, both of the lungs, the middle to distal
Median sternotomy/anterolateral thoracotomy/ trachea, and the left mainstem bronchus. It is quick to
perform, bloodless, and causes less postoperative pain and
clamshell fewer respiratory complications than a thoracotomy.
Supine position, abducted arms. However, it does not provide good exposure of the
posterior mediastinal structures and does not provide
Posterolateral thoracotomy adequate access for cross-clamping of the thoracic aorta
The patient is placed in a lateral decubitus position for resuscitation purposes.
with the hips secured to the table by wide adhesive The incision is made over the center of the sternum,
tape. Bean bags should be used to provide additional extending from the suprasternal notch to the xiphoid and
support. is carried down to the sternum.
The lower leg is flexed at the knee, while the upper leg is The sternum is scored in the midline with electrocautery to
straight and a pillow is placed between the knees. direct the saw or the Lebsche knife, which is then used to
A rolled sheet is placed under the axilla to support the divide the sternum.
shoulder and upper thorax. The interclavicular ligament at the suprasternal notch is
The arm on the side of the thoracotomy is extended cleared from its attachment to the sternum using a
forward and upward (praying position) and placed in a combination of cautery and blunt dissection, always staying
padded grooved arm holder in line with the head. close to the bone to avoid injuring the underlying vessels.
Confirm clearance of the posterior wall of the suprasternal
Overextension can lead to brachial nerve injury. notch by passing the index finger behind the manubrium.
The lower arm is extended and placed on a board at 90
degrees. Note that the pneumatic saw does not work in the
presence of soft tissues!
Place the hook of the pneumatic saw or the Lebsche knife
under the suprasternal notch and lift the sternum upwards.
Ask anesthesia to hold ventilation and divide the
sternum directly in the midline, maintaining upwards
traction along the entire length.
Place the Finochietto retractor in the upper part of the
sternotomy and spread the sternum.
Fig. 14.4. The median
Suprasternal sternotomy extends from
the suprasternal notch to
notch the xiphoid and is carried
down to the sternum. The
sternum is scored in the
midline with the knife or
electrocautery, to direct
the saw or the Lebsche
Fig. 14.3. Positioning of the patient for a posterolateral thoracotomy. knife to stay in the middle
of the sternum.
Incision(s)
The selection of incision should be based on the clinical
condition of the patient, the location of the operation (emer- Scoring of the
gency room versus operating room), the need for thoracic middle
aortic cross-clamping, the location of any penetrating of the sternum
injuries and the suspected injured organs. Incisions such
as a posterolateral thoracotomy requiring special time-
consuming positioning of the patient should be avoided in Xiphoid
the unstable patient.
108
Chapter 14. Chest trauma operations
(a) (a)
Clearance of the interclavicular Xiphoid

ligament
(b)
Digital confirmation
of the clearance
of the soft tissues
behind the manubrium
Head
(b)
Head
Xiphoid
Fig. 14.5(a),(b). The interclavicular ligament at the suprasternal notch is

cleared from its attachment to the sternum using a combination of cautery and
blunt dissection (a). The clearance is confirmed by passing the index finger
behind the manubrium (b).
Fig. 14.6(a)–(c). Division of the sternum with the pneumatic saw (a) and the
Lebsche knife (b). A Finochietto retractor is placed in the upper part of the
sternotomy and the sternum is spread open (c).
109
Section 5: Chest
(b)
(c) Finochietto placed in the
superior sternum
Fig. 14.6(a)–(c). (cont.)
Closure of median sternotomy

Ensure good hemostasis along the divided bone edge with
cautery or bone wax.
Check for any bleeding under the sternum from the internal
mammary arteries after removal of the sternal retractor.
Place at least one waterseal chest drain under the sternum,
and place additional drains in open chest cavities.
Close the sternum with steel wires, using the heavy needle
driver.
Close the presternal fascia with heavy absorbable sutures.
(a)
Fig. 14.7(a),(b). (cont.)
This is the incision of choice for resuscitative thoracotomy,
suspected injuries to the lung or the posterior heart, and
cross-clamping of the aorta for resuscitation; it provides
poor exposure of the anterior mediastinal vessels.
Mark the incision with a marking pen prior to skin incision.
The incision is made through the fourth to fifth intercostal
space (below the nipple in males, infra-mammary fold in
females), starting from the parasternal border and extending
to the posterior axillary line, aiming towards the axilla.
The pectoralis major and pectoralis minor are encountered
and divided in the anterior part of the incision.
The serratus anterior muscle is encountered and divided in
the posterior part of the incision.
The intercostal muscles are then divided close to the superior
border of the rib in order to avoid the neurovascular bundle,
and the pleural cavity is entered with the use of scissors,
taking care to avoid injuring the underlying inflated lung.
Withholding ventilation during entry into the pleural
cavity reduces the risk of iatrogenic lung injury.
A Finochietto retractor is then placed and the ribs are
Fig. 14.7(a),(b). Closure of the median sternotomy with steel wires. spread slowly to avoid rib fractures.
110
(a) (a)
Incision curves
towards the axilla
Pectoralis major m
(b) (b)
Division of
pectoralis major m.
Fig. 14.8(a),(b). The incision for an anterolateral thoracotomy is placed Fig. 14.9(a)–(e). Anterolateral thoracotomy: the pectoralis major muscle is
through the fourth to fifth intercostal space, starting from the parasternal encountered in the anterior part of the incision and is divided (a), (b). The lower
border and extending to the posterior axillary line, aiming towards the axilla. part of the pectoralis major is encountered under the pectoralis major and
divided (c). The serratus anterior muscle is encountered and divided in the
lateral part of the incision. The intercostal muscles are then divided with the use
of scissors, close to the superior border of the rib (d). A Finochietto retractor is
then placed and the ribs are spread slowly to avoid rib fractures (e).
111
Section 5: Chest
(c) (e)
Heart
ib Divided pectoralis Left lower lung

Fifth r
minor m.
Diaphragm
Divided
pectoralis major m.
(d) Fig. 14.9(a)–(e). (cont.)
Closure of anterolateral thoracotomy incision

Insert a thoracostomy tube at the mid axillary line.
Close the chest wall in layers, reapproximating the
divided muscles with heavy figure-of-eight absorbable
sutures.
Clamshell incision
It is usually performed as an extension of a standard
anterolateral thoracotomy to the opposite side, for
suspected bilateral lung injuries, superior mediastinal
Superior border vascular injuries or cardiac resuscitation and aortic
of the rib cross-clamping.
It provides good exposure of the anterior aspect of the
heart, the superior mediastinal vessels (aortic arch and
branches, superior vena cava and innominate veins), and
both lungs.
The incision is made through the fourth to fifth intercostal
spaces bilaterally with transverse division of the sternum,
using bone cutters or heavy scissors.
During division of the sternum, both internal mammary
arteries are transected and identification and ligation of the
proximal and distal ends should be performed.
Fig. 14.9(a)–(e). (cont.)
112
(a) Posterolateral thoracotomy

This approach requires special patient positioning. It is
usually indicated for injuries to the descending aorta,
thoracic esophagus, distal trachea, and mainstem bronchi.
For optimal exposure of the upper portion of the thoracic
cavity, the chest is entered through the fourth or fifth
intercostal space.
A thoracotomy through the fifth intercostal space
allows good access to the pulmonary hilum and is
considered the approach of choice for major
pulmonary resections.
A low left posterolateral thoracotomy through the sixth or
seventh intercostal space provides good exposure to the
distal third of the thoracic esophagus, and a high right
Transverse division thoracotomy through the fourth intercostal space provides
of the sternum good access to the upper and middle esophagus.
A curvilinear skin incision is made, extending from the
anterior axillary line, coursing approximately one to two
finger breadths below the tip of the scapula, and extending
(b)
posteriorly and cephalad midway between the spine and
the medial border of the scapula (the tip of the scapula is
usually over the sixth or seventh intercostal space).
The latissimus dorsi is identified and divided in line with
the incision using electrocautery.
The serratus anterior muscle is then divided as low as
Sternum
possible to minimize the amount of denervated muscle.
In the same plane posteriorly, the trapezius muscle (or
more superiorly the rhomboid muscles) may need to be
divided for additional exposure.
The scapula is elevated using a scapula retractor, the
Heart appropriate intercostal space is selected and the pleural
cavity is entered at the superior border of the rib, in order
Sternum to avoid injuring the neurovascular bundle.
Resection of a 3 cm to 4 cm portion of the fifth or sixth rib
posteriorly improves exposure and prevents iatrogenic
fracturing of the ribs.
Gunshot wound lung

Closure of posterolateral thoracotomy
Fig. 14.10(a),(b). The clamshell incision is made through the fourth to fifth Approximation of the divided muscles and the
intercostal space bilaterally, with transverse division of the sternum. It provides
good exposure of the anterior aspect of the heart, the superior mediastinal
subcutaneous tissue as described in the anterolateral
vessels, and both lungs. thoracotomy.
Closure of clamshell incision

The divided sternum is reapproximated with steel wires
and the thoracotomy incisions are closed as
described above.
113
Section 5: Chest
Tips and pitfalls

Sternotomy incision
Failure to divide the interclavicular ligament at the
suprasternal notch and clear its attachments to the
sternum causes malfunction of the pneumatic saw, as
the pneumatic saw does not work in the presence of soft
tissues.
The median sternotomy goes off midline, through the
costal cartilages. This complicates the closure and
increases the risk of sternal dehiscence. To avoid this
problem, score the sternum in the midline with
electrocautery to guide the saw or the Lebsche knife.
The sternal retractor is placed in the lower part of the
sternotomy. This is the weakest part of the sternum and
increases the risk of sternal fracture. Place the retractor
in the upper part of the median sternotomy.
The incision does not follow the intercostal space,
making entry into the chest cavity difficult and messy!
The incision should curve upward, directed towards the
axilla.
Excessive spreading of the rib retractor may cause rib
fractures and increase postoperative pain.
Failure to inspect for injury to the left internal
Fig. 14.11. The skin incision for a posterolateral thoracotomy extends from mammary artery after removal of the retractor. The
the anterior axillary line, coursing about 1–2 finger breadths below the tip
of the scapula, and extends posteriorly and cephalad midway between
blades of the retractor may obscure an injury to the
the spine and the medial border of the scapula. artery with subsequent bleeding.
Failure to approximate the divided muscles in layers
may result in functional and aesthetic problems.
Clamshell incision
Failure to identify and ligate all four ends of the two
divided internal mammary arteries.
Posterolateral thoracotomy
Latissimus dorsi muscle The incision is too low or too high resulting in poor
exposure.
Making the skin incision over the scapula results in
Serratus anterior muscle poor aesthetic results. The incision should be one to
two finger breadths below the tip of the scapula.
Fig. 14.12. Left posterolateral thoracotomy through the sixth or seventh

intercostal space. The latissimus dorsi and the serratus anterior muscles are
divided. More posteriorly, the trapezius muscle (or more superiorly the
rhomboid muscles) may need to be divided for additional exposure.
114
Section 5 Chest
Cardiac injuries
Chapter
15 Demetrios Demetriades and Scott Zakaluzny
Surgical anatomy SVC
The pericardium envelops the heart and attaches to the

roots of the great vessels. This includes the ascending aorta, Aortic arch
pulmonary artery, pulmonary veins, the last 2 cm to 4 cm
of superior vena cava, and inferior vena cava.
Pulmonary artery
The phrenic nerves descend on the lateral surfaces of the
pericardium.
Pericardium
Acute accumulation of as little as 200 mL of fluid in the
pericardial sac may result in fatal cardiac tamponade.
The right atrium is paper thin, approximately 2 mm. The LADA
left atrium is slightly thicker at approximately 3 mm.
The right ventricle is approximately 4 mm thick
and the left ventricular wall thickness is approximately
12 mm.
The two main coronary arteries, left main and right
coronary arteries, originate at the root of the aorta, as it
exits the left ventricle. The left main coronary artery
divides into the left anterior descending artery (LAD) and
the circumflex artery, and provides blood supply to the left Fig. 15.1. Surface anatomy of the heart and the great vessels. Note the
heart. The right coronary artery divides into the right attachment of the pericardium to the roots of the major vessels.
posterior descending and acute marginal arteries,
supplying blood to the right heart as well as to the
sinoatrial and atrioventricular nodes, responsible for
regulating cardiac rhythm. The majority of cardiac injuries are due to penetrating
trauma from stab wounds or gunshot wounds. Stab wounds
usually involve the right ventricle and gunshot wounds often
damage multiple chambers or internal cardiac structures.
General principles Cardiac rupture due to blunt trauma is usually fatal and the
Cardiac injuries are highly lethal and most victims die at victims die before reaching medical care.
the scene. In those who survive to the emergency Patients with no vital signs or imminent cardiac arrest on
department, immediate diagnosis and surgical intervention arrival should be managed with a resuscitative emergency
remain the cornerstones of survival. The diagnosis is based room thoracotomy (see Chapter 4).
on clinical examination and the Focused Assessment Cardiac bypass is almost never required during the
Sonography for Trauma (FAST) exam. There is no role for initial operation for cardiac repair. The use of temporary
diagnostic pericardiocentesis in a hospital environment. intra-aortic balloon pump augmentation may be
Most patients have no signs of life or have severe considered.
hypotension on arrival. If there is a short prehospital time Injuries to the low-pressure cardiac chambers may be
or small cardiac injury, the patient may arrive with normal complicated by air embolism. Look for air bubbles in the
initial vital signs. coronary veins. If seen, aspirate the right ventricle.
115
Section 5: Chest
Special surgical instruments This incision is fast, does not need power instruments, and
allows cross-clamping of the thoracic aorta for
The emergency room thoracotomy tray should be kept resuscitation purposes (see Chapter 4).
simple, with only the absolutely necessary instruments
In most patients undergoing an operation in the operating
(scalpel, Finochietto retractor, two Duval lung forceps, two
room, a median sternotomy is the incision of choice. It
vascular clamps, one long Russian forceps, four hemostats,
provides good exposure to the heart and both lungs, it is
one bone cutter, one pair of long scissors, one pair of suture
relatively bloodless and is associated with less postoperative
scissors). In addition, good lighting, working suction, and
pain and fewer complications. However, the exposure of the
an internal defibrillator should be immediately available.
posterior heart or cross-clamping of the aorta may be difficult.
In the operating room, the thoracotomy trauma tray should
A left thoracotomy in the operating room is preferable to
include a power sternal saw, Lebsche knife with hammer,
sternotomy in patients who might need cross-clamping of
and bone cutter. The surgeon should wear a headlamp for
the aorta or in suspected cases of injury to the posterior
optimal lighting in anatomically difficult areas.
wall of the heart.
Extension of the left thoracotomy into the right chest to
create a clamshell incision may be required in patients with
bilateral chest trauma (see Chapter 14).
Media sternotomy incision

The incision is made over the center of the sternum,
extending from the suprasternal notch to the xiphoid. The
incision is carried through the sternocostal radiate ligaments,
down to the sternum. The interclavicular ligament, at the
suprasternal notch, is cleared from its attachment to the
sternum, using a combination of cautery and blunt
dissection with a right angle. Confirm the clearance of the
posterior wall of the suprasternal notch by passing the index
finger behind the manubrium. The pneumatic saw does not
Fig. 15.2. Instruments required for median sternotomy: sternal power saw, work in the presence of soft tissues! Score the sternum in the
Lebsche knife, hammer, Finochietto retractor.
midline with electrocautery to direct the saw or the Lebsche
knife to stay in the middle during the sternal division.
Patient positioning
For an emergency room left thoracotomy, the patient
remains supine on the gurney, with the left arm abducted or Suprasternal
elevated above the head. Antiseptic solution is applied on the notch
skin over the anterior chest and both hemithoraces. There is
no time for draping or meticulous antiseptic precautions.
In the operating room the patient is placed in the supine
position with both arms abducted at 90 degrees to allow
anesthesia access to the extremities. The left arm may be
elevated further above the head if a left anterolateral
thoracotomy is to be performed. The skin preparation and Scoring of the
midline of
draping should include the anterior chest and both
the sternum
hemithoraces. The abdomen should be included if there are
suspected associated intra-abdominal injuries.
Incisions
The choice of incision depends on the clinical condition of the
patient, the location of the operation (emergency room or
Xiphoid
operating room), the need for thoracic aortic cross-clamping,
and the suspected anatomical site of cardiac injury.
Patients transported to the emergency room with no vital
Fig. 15.3. Median sternotomy incision extends from the suprasternal notch
signs or in imminent cardiac arrest should undergo an superiorly to the xiphoid process inferiorly, and is carried down to the sternum.
immediate left antero-lateral thoracotomy on the gurney. The sternum is scored in the midline to guide the sternal saw.
116
Chapter 15. Cardiac injuries
(a) (a)
Head
Dissection of
supraclavicular
ligament
Suprasternal
notch
(b)
Head
Head
Suprasternal
notch
(b)
Fig. 15.4(a),(b). The interclavicular ligament is divided, using a combination

of cautery and blunt dissection with an angled forceps, prior to division
of the sternum with the saw or Lebsche knife. Palpation with a finger of the
posterior surface of the sternal notch confirms that soft tissues have been
dissected free prior to dividing the sternum.
Place the hook of the pneumatic saw or the Lebsche knife

under the suprasternal notch and lift upward on the
sternum. Ask anesthesia to hold ventilation temporarily
and divide the sternum, maintaining an upwards traction
and always staying in the midline.
Place the Finochietto retractor in the upper part of the
sternum and spread open. The anterior pericardium is now
exposed.
Fig. 15.5(a),(b). The hook of the saw or Lebsche knife is placed under the
suprasternal notch and the sternum is lifted slightly upward. The sternum is
divided with constant upward traction, always keeping in the scored midline.
117
Section 5: Chest
The median sternotomy goes off midline, through the

Head
costal cartilages. To avoid this problem, score the sternum
in the midline with electrocautery to direct the saw or the
Lebsche knife and stay in the middle.
Placement of the Finochietto retractor in the lower part of
the sternum may cause transverse fracture of the sternum.
The retractor should be placed in the upper part where the
sternum is thicker and stronger.
Anterior During left thoracotomy: (a) The incision is made
pericardium too low. This risks injury to an elevated diaphragm
and poor exposure of the upper part of the heart.
Do not go below the fourth to fifth intercostal space.
(b) The incision does not follow the intercostal space,
making entry into the chest difficult and messy!
The incision should curve with a direction towards
Xiphoid the axilla.
Failure to inspect for injury to the left internal mammary
artery after removal of the retractor. The blades of the
retractor may obscure any injury to the artery and
subsequent bleeding.
Fig. 15.6. The sternum is spread open with a Finochietto retractor and the
pericardium is exposed. Pericardiotomy
In the absence of tense cardiac tamponade, the
pericardium is grasped in the midline with two hemostats
and a small pericardiotomy incision is made. In the
Left thoracotomy incision presence of a tense tamponade it is difficult to apply the
hemostats on the pericardium. In these cases a small
The incision is made through the left fourth to fifth pericardiotomy is performed with a scalpel and the
intercostal space (below the nipple in males, in the pericardium is then opened longitudinally with scissors.
inframammary fold in females), starting from the left of If a median sternotomy is performed, the pericardiotomy
the parasternal border and extending to the posterior is performed in the midline. With a left thoracotomy, the
axillary line. Follow the curve of the ribs by aiming towards left phrenic nerve is seen along the lateral surface of the
the axilla (see Chapter 14). pericardium and the pericardiotomy is performed
The pectoralis major and pectoralis minor are encountered superiorly and parallel to the phrenic nerve.
and divided in the anterior part of the incision. The
serratus anterior muscle is encountered and divided in the (a)
posterior part of the incision (see Chapter 14).
The intercostal muscles are then divided close to the
Head
superior border of the rib, in order to avoid the
neurovascular bundle, and the pleural cavity is entered with
the use of scissors taking precautions to avoid injury to the
underlying inflated lung (see Chapter 14). Hemostats lifting
Right-stem intubation or withholding ventilation during pericardium
entry into the pleural cavity reduce the risk of iatrogenic
lung injury. Heart
A Finochietto retractor is then applied and the ribs are
spread (see Chapter 14).
Dome of left
diaphragm
Tips and pitfalls
During sternotomy, failure to divide the interclavicular
ligament at the suprasternal notch and clear its attachment
Fig. 15.7(a). The non-tense pericardium can be grasped and elevated with
to the sternum. The pneumatic saw does not work in the hemostats in order to safely make a pericardiotomy without injuring the
presence of soft tissues! underlying heart.
118
(b) (d)
Head
Xiphoid
Head
Fig. 15.7(d). Tense cardiac tamponade is released through the

pericardiotomy.
(a)
Xiphoid
Head
Heart
(c)
Dome Left lung
Head left diaphragm
Phrenic n
Fig. 15.8(a). The pericardiotomy through a left thoracotomy should be
performed in front of the left phrenic nerve. The tip of the forceps shows the
site of the pericardiotomy, in front of the nerve.
(b)
Heart
Xiphoid
Fig. 15.7(b),(c). In the presence of a tense cardiac tamponade, the Fig. 15.8(b). The pericardium is opened and the heart exposed.
pericardium is entered with a scalpel and opened longitudinally with scissors.
119
Section 5: Chest
Tips and pitfalls (b)

In patients with a tense pericardium, it may be difficult to
grasp the pericardium. Make a small pericardiotomy with a
scalpel to facilitate entry. Locate and avoid cutting the
phrenic nerve.
Bleeding control and cardiac repair

After the pericardiotomy and release of the tamponade,
any direct cardiac bleeding is controlled by finger
compression. For larger atrial injuries, a vascular clamp
may be used, taking care not to worsen the injury.
For emergency room thoracotomies where a small
cardiac injury is found, temporary bleeding control
may be achieved by inserting and inflating a Foley
catheter.
The cardiac wound is repaired with figure-of-eight, Fig. 15.9(b). Most cardiac wounds can be repaired with figure-of-eight
stitches of non-absorbable 2/0 or 3/0 suture on a tapered needle.
horizontal mattress or running sutures, using
non-absorbable 2/0 or 3/0 suture on a large tapered
(c)
needle. Routine use of pledgets is time consuming and
unnecessary in the majority of cases and should be
reserved for cases where the myocardium tears during
tying the sutures.
Injuries close to a major coronary vessel should be repaired
with horizontal mattress sutures under the vessel.
(a)
Fig. 15.9(c). Repair of a right ventricular wound with figure-of-eight sutures.
Fig. 15.9(a). Digital compression between the thumb and index finger is used
initially to control bleeding from the cardiac wound and allow suturing.
120
(a)
(b)
Fig. 15.10(a),(b). (cont.)
required. If arrhythmia occurs, the suture is removed and

gentle finger pressure is applied, while a cardiac team with
Fig. 15.10(a),(b). A Foley balloon can be used to temporarily control the cardiopulmonary bypass capabilities is mobilized.
bleeding from a cardiac wound. Exert gentle traction on the catheter to achieve
tamponade of the wound. Avoid excessive traction to prevent pulling the Cardiopulmonary bypass is largely unnecessary during
balloon through the defect and creating a larger wound. the acute operation. The surgical goal is to save the
patient’s life. Any non-life-threatening intracardiac defects
Skin staples may be used temporarily for cardiac wound should be repaired electively under optimal conditions at
closure in the emergency room, and are primarily effective a later stage.
for stab wounds. This does not work well in patients who Inspection and repair of injuries to the posterior cardiac
have sustained gunshot wounds associated with cardiac wall can be difficult, as lifting of the heart often causes
tissue loss. The staples should be replaced by sutures in the arrhythmia or cardiac arrest. These injuries can be
operating room. exposed and repaired by grasping the apex of the heart
Partial transection of a major coronary artery can be with a Duval clamp and applying mild traction and
repaired with interrupted sutures under magnification, elevation. Another option is to place a figure-of-eight
while the heart is beating. If this is not technically 2–0 suture on a tapered needle through the apex of the
possible, ligation is performed and the cardiac activity heart for traction and elevation. This option should be
is observed. Distal injuries are usually tolerated well. performed cautiously because the myocardium may
If no arrhythmia develops, then nothing further is tear during traction. An alternative approach is to
121
Section 5: Chest
slowly elevate the heart by placing sequential (a)

laparotomy pads, one at a time, under the heart to
allow adaptation to the change in position. Inflow Apex of heart
occlusion of the superior and inferior vena cava, in order to
induce cardiac arrest and facilitate repair of the wound, is
Posterior heart
not advisable, because it is unlikely that the already
compromised heart will tolerate normothermic cardiac
arrest, even for brief periods of time.
In cases of persistent arrhythmias or cardiac arrest, use
epicardial pacing (see Chapter 4).
Diaphragm
(a)
Fig. 15.12(a),(b). The posterior aspect of the heart can be exposed and
repaired by grasping the apex with a Duval clamp and gently elevating the heart.
(b)
LADA
Posterior heart
(b) Diaphragm
Fig. 15.12(a),(b). (cont.)
Pericardial closure
Coronary art Following cardiac repair and stabilization of the patient, the
pericardium is closed with continuous 2–0 sutures, leaving an
opening near the base of the pericardium to avoid tamponade
in case of a rebleed. In patients with acute cardiac enlargement
due to cardiac failure or massive fluid resuscitation, the peri-
cardium should be left open to prevent arrhythmias.
Fig. 15.11(a),(b). Injuries near coronary vessels should be repaired with a

horizontal mattress suture, placed under the vessel.
Tips and pitfalls
Closure of the pericardium under tension may precipitate
an arrhythmia and cardiac arrest.
122
Closure of median sternotomy (b)
Ensure hemostasis of the sternal edge with cautery or bone

wax application.
Check for bleeding from the internal mammary arteries, under
the sternum, after removal of the sternal retractor.
Place at least one water-sealed chest drain under the sternum.
Close the sternum with steel wires, using the heavy needle
driver.
Close the presternal fascia with heavy absorbable sutures.
(a)
Head
Fig. 15.13(a)–(d). (cont.)

Xiphoid
Fig. 15.13(a)–(d). Closure of the sternotomy in layers. The sternum is closed

with wires and the fascia with heavy, continuous absorbable suture.
123
Section 5: Chest
(c) (d)
Closed presternal
fascia
Fig. 15.13(a)–(d). (cont.)
Fig. 15.13(a)–(d). (cont.)
124
Tips and pitfalls Postoperative evaluation

Failure to inspect the integrity of the inferior All survivors should undergo routine early and late echocardio-
mammary artery after the removal of the sternal graphic evaluation to rule out significant intracardiac injuries,
retractor can result in significant and persistent which include septal defects, valvular or papillary muscle dys-
postoperative bleeding. function, myocardial dyskinesia, and late pericardial effusion.
125
Section 5 Chest
Thoracic vessels
Chapter
16 Demetrios Demetriades and Stephen Varga
Surgical anatomy The right innominate (brachiocephalic) vein is approximately

3 cm in length, courses vertically downward and joins the left
The upper mediastinum contains the aortic arch with the innominate vein at a 90 degree angle, to form the SVC.
origins of its major branches. These include the
The SVC is approximately 6–7 cm in length and is located
innominate artery, proximal left common carotid, and
lateral and parallel to the ascending aorta. A small segment
proximal left subclavian arteries. The left and right
is enclosed within the pericardium.
innominate veins join to become the superior vena
cava (SVC). The ascending aorta is contained within the pericardium.
The aortic arch begins at the superior attachment of the
The thymic remnant and surrounding mediastinal fat are
pericardium. The first branch of the aortic arch is the
the first tissues encountered when entering the upper
innominate (brachiocephalic) artery, which branches into the
mediastinum. These tissues lie over the left innominate
right subclavian and right common carotid arteries. The next
(brachiocephalic) vein and the aortic arch.
branch of the arch is the left common carotid artery, followed
The left innominate vein is approximately 6–7 cm long, by the left subclavian artery. The innominate artery and the
transverses the upper mediastinum under the manubrium
left common carotid originate relatively anteriorly, while the
sterni and over the superior border of the aortic arch. It
left subclavian artery originates more posteriorly. Anatomical
joins the right innominate vein, at the level of the first to
variants include a common origin for the left common
second intercostal space on the right parasternally, to form
carotid artery and innominate artery as well as a common
the SVC.
origin for the left subclavian and left common carotid artery.
Innominate artery Left CCA Fig. 16.1. Anatomy of the vessels of the superior
mediastinum. Note the left innominate vein
transversing over the superior border of the aortic
arch and its major branches (SVC ¼ superior vena
Left internal jugular cava, RLN ¼ recurrent laryngeal nerve, CCA ¼
common carotid artery.)
Left subclavian vein
Right Left subclavian artery

innominate vein
Left innominate vein Left vagus nerve
RLN
SVC
Pulmonary vein trunk
126
Chapter 16. Thoracic vessels
Fig. 16.2. The roots of the major vessels (aorta, superior vena cava, and
pulmonary trunk) are covered by the pericardium.
Aortic arch
SVC Pulmonary trunk
Pericardium
VA Fig. 16.3. The major vessels of the aortic arch

(innominate artery, left common carotid, left
Right subclavian artery). The left common carotid
originates directly from the aorta, while the right
CCA Costocervical artery
common carotid branches from the innominate
artery. (SCA ¼ subclavian artery, CCA ¼ common
TCT carotid artery, VA ¼ vertebral artery, IMA ¼ internal
Left mammary artery, TCT ¼ thyrocervical trunk.)
CCA
Right SCA IMA
Left SCA
Innominate artery Aortic
arch
Fig. 16.4. Anatomy of the aortic arch and its

major trunks; note the anatomical relationship with
the left innominate vein, the left vagus, and left
Left phrenic nerves. The vagus nerve is medial and the
Left IJV
CCA phrenic nerve lateral to the internal mammary
VA
artery. (SCA ¼ subclavian artery, SCV ¼ subclavian
Innominate artery vein, CCA ¼ common carotid artery, VA ¼ vertebral
artery, IMA ¼ internal mammary artery, RLN ¼
Divid Left SCV recurrent laryngeal nerve.)
ed cl
avicle
Left SCA
v
om inate Phrenic nerve
Left inn
Left IMA
Aorta
Vagus nerve
RLN
Divided sternum
127
Section 5: Chest
The left vagus nerve travels between the left common carotid loops behind the subclavian artery and ascends behind the
and subclavian arteries just anterior to the arch and branches common carotid artery along the tracheoesophageal groove.
off into the recurrent laryngeal nerve, which loops around the The thoracic or descending aorta begins at the fourth
aortic arch and ascends along the tracheoesophageal groove. thoracic vertebra on the left side of the vertebral column.
The right vagus nerve crosses over the right subclavian artery, Below the root of the lung, it courses to a position anterior
immediately gives off the recurrent laryngeal nerve, which to the vertebral column as it passes into the abdominal
cavity through the aortic hiatus in the diaphragm at the
twelfth thoracic vertebra.
The esophagus lies on the right side of the aorta
proximally. Distally, as it enters the diaphragm, it courses
in front of the aorta.
The aorta has nine pairs of aortic intercostal arteries that arise
Right Left from the posterior of the aorta and travel to the associated
CCA CCA intercostal spaces. The bronchial and esophageal arteries are
additional branches of the aorta as it descends in the thorax.
Vagus nerve
Vagus nerve
Head
Left SCA
Right SCA Esophagus
IMA
Retracted
left lung
Aorta
RLN
Fig. 16.5. Anatomical relationship between the vagus nerves and the major
vessels. They cross in front of the proximal subclavian artery. The recurrent
laryngeal nerve loops around the subclavian on the right side and around the
aortic arch on the left side. (SCA ¼ subclavian artery, CCA ¼ common carotid
artery, IMA ¼ internal mammary artery, RLN ¼ recurrent laryngeal nerve.)
Fig. 16.7. Anatomical relationship between the esophagus and the thoracic
aorta: the esophagus lies on the right side of the aorta. Above the diaphragm, it
courses in front of the aorta.
Fig. 16.6. The left vagus nerve crosses over the

proximal left subclavian artery and the aortic arch.
At the inferior border of the arch it gives the left
recurrent laryngeal nerve. (SCA ¼ subclavian artery,
HEAD RLN ¼ recurrent laryngeal nerve).
Phrenic n
Left SCA
Aorta
Vagus n
RLN
Aorta
128
General principles The median sternotomy incision can also be extended into
the neck with a sternocleidomastoid incision or a clavicular
Greater than 90% of thoracic great vessel injuries are due to
extension to allow more distal exposure of the common
penetrating trauma. Most patients with penetrating trauma
carotid or the subclavian vessels.
to the major mediastinal vessels die at the scene and never
reach hospital care.
For those who survive to present to a hospital, most
patients arrive with hemodynamic instability and require
emergency operation without any diagnostic studies.
Patients with no vital signs or imminent cardiac arrest on
arrival should be managed with a resuscitative emergency
room thoracotomy (see Chapter 4).
In hemodynamically stable patients with suspected injuries
to the mediastinal vessels, CT arteriography is the most
effective screening diagnostic investigation.
Thoracic great vessel injuries can present with external or
internal hemorrhage, vascular thrombosis from intimal
flaps, or pseudoaneurysms. Consequently, the absence of a
significant amount of bleeding does not rule out a vascular
injury.

In the operating room, the thoracotomy trauma tray
should include vascular instruments, a power sternal saw,
Lebsche knife with hammer, and bone cutter. The surgeon
should wear a headlight for optimal lighting in
anatomically difficult areas.
Patient positioning
Fig. 16.8. The median sternotomy incision may be extended into the neck
Positioning for upper mediastinal vascular injuries with a sternocleidomastoid incision for improved exposure of the common
The patient is placed in the supine position with both arms carotids or a clavicular incision to allow more distal exposure of the subclavian
vessels.
abducted at 90 degrees to allow anesthesia access to the
extremities.
Skin preparation and draping should include the neck,
anterior chest, and hemithoraces. As for all acute trauma
operations, the abdomen and groin should be prepared as
Clamshell incision
well in case of an unexpected missile trajectory or the need The clamshell incision provides good exposure of the
for saphenous vein conduit. anterior aspect of the heart, the superior mediastinal
vessels, and both lungs. It is usually performed as an
extension of a standard anterolateral thoracotomy to the
Positioning for exposure of the descending opposite side.
thoracic aorta The incision is made through the fourth to fifth intercostal
Place patient in right lateral decubitus position (see space bilaterally with transverse division of the sternum,
Chapter 14). using a bone cutter or heavy scissors.
If possible use a double-lumen endotracheal tube and have During the division of the sternum, both internal
the left lung deflated once the pleura has been entered. mammary arteries are transected, and identification and
ligation of the proximal and distal ends should be
performed.
Incisions
Median sternotomy
A median sternotomy provides excellent exposure of the
upper mediastinal vessels. In addition, it provides good
exposure to the heart and to both lungs.
129
Section 5: Chest
(a) Perform a generous left posterior lateral thoracotomy in the

fourth or fifth intercostal space just below the left nipple all
the way up between the scapula and the spine, making sure
to divide the latissimus dorsi and the serratus anterior.
Divided sternum
(b)
HEAD
Fig. 16.10. Positioning and incision for the exposure of the descending
thoracic aorta.
Exposures
Exposure of the upper mediastinal vessels
Divided sternum Following median sternotomy or clamshell incision, the
first step is to open the pericardium to rule out injury to
the heart or the intrapericardial segment of the great
vessels.
Fig. 16.9(a),(b). The clamshell incision is made through the fourth to fifth
intercostal space bilaterally with transverse division of the sternum. It provides a All mediastinal hematomas due to penetrating trauma
good exposure of the anterior aspect of the heart, the superior mediastinal should be explored, if possible after proximal and distal
vessels, and both lungs. control.
The first tissues encountered under the sternum in the upper
mediastinum are the thymus remnant with surrounding fat
pad, which lies directly over the left innominate vein and the
Posterolateral thoracotomy aortic arch. These tissues are grasped with an Allis forceps
This is the optimal incision for the management of injuries and lifted towards the patient’s head. Careful blunt dissection
to the descending thoracic aorta. However, in the majority exposes the left innominate vein.
of penetrating trauma cases, due to severe hemodynamic Vessel loops are placed around the left innominate vein.
instability, the patient is placed in the supine position and Dissection of the vessel allows identification of its near
an extended anterolateral incision is performed. perpendicular junction with the right innominate vein,
If possible, use a double-lumen endotracheal tube and have where the SVC begins. The SVC lies parallel and to the
the left lung deflated once the pleura has been entered. right of the ascending aorta.
130
(a) (b)
HEAD Head
Mobilized thymus
and fat
Left innominate
vein
Left innominate vein

Ascending aorta
Right lung Left lung

Right lung Left lung
Heart
Heart
Fig. 16.11(a),(b). Mobilization of the thymus and upper mediastinal fat pad. The first tissues encountered under the sternum in the upper mediastinum are
the thymus remnant with the surrounding fat pad, which lie directly over the left innominate vein and the aortic arch. Mobilization of these tissues exposes
the left innominate vein, which is encircled with a vessel loop.
Head Exposure of the aortic arch and the origins of the major
vessels requires retraction of the left innominate vein,
which lies directly over the upper border of the arch. On
rare occasions, the left innominate vein may need to be
ligated to provide better exposure of the transverse aorta
and its branches.
The innominate and left carotid arteries originate from the
Left innominate
anterosuperior aspect of the aortic arch and are easy to
vein
identify and control with vessel loops. However, the left
Ascending aorta subclavian artery is more posterior and more difficult to
SVC
isolate.
Mobilization and isolation of the distal innominate artery
may be difficult through a median sternotomy. In these
cases the incision may be extended to the right neck
through a standard sternocleidomastoid incision, to
improve the exposure.
Mobilization and isolation of the left subclavian artery may
Heart require a combination of a median sternotomy with a left
clavicular incision.
Identify and protect the left vagus nerve as it descends into
the mediastinum between the left carotid and the left
subclavian arteries, over the aortic arch.
Fig. 16.12. Complete mobilization of the left innominate vein and

exposure of the superior vena cava.
131
Section 5: Chest
(a) Fig. 16.13(a)–(c). The proximal innominate artery

and left common carotid artery lie directly under the
left innominate vein (a). The left subclavian artery is
lateral and more posterior and needs further
dissection for exposure (b). Complete exposure of
the left innominate vein (formed by the left internal
jugular and left subclavian veins) and the trunks of
HEAD the aortic arch. (SCA ¼ subclavian artery, CCA ¼
common carotid artery, IJV ¼ internal jugular vein,
SCV ¼ subclavian vein.)
Left IJV
Left SCV
Left innominate
vein
Left CCA
Innominate artery
Aortic
arch
(b)
HEAD
Left SCA
Left CCA
Innominate artery
Left innominate
vein
ch
tic ar
Aor
132
(c) Fig. 16.13(a)–(c). (cont.)
HEAD Left IJV
Left SCA
Left CCA
Innominate artery
Left SCV
Left innominate
vein
h
c arc
Aorti
(a) (b)
HEAD HEAD
Left innominate
vein Left innominate
vein
Innominate a Left CCA
Left lung Innominate a

Right lung
Left lung
Right lung Aortic
arch
Fig. 16.14(a)–(c). The left innominate vein may be ligated and divided to allow for greater exposure to the transverse aorta and proximal innominate artery.
133
Section 5: Chest
(c) HEAD
Right CCA
HEAD
Left CCA
Innominate a
Right SCA
Left SCA
Innominate artery
Divided
left innominate v
Aortic
Aortic
arch
Right lung arch
Left CCA
HEART
Fig. 16.14(a)–(c). (cont.) Fig. 16.15. The aortic arch after division of the left innominate vein.
The innominate artery, with the origins of the right common carotid and
right subclavian arteries are identified. Note the limited exposure of the left
subclavian artery due to its posterior position. (SCA ¼ subclavian artery,
CCA ¼ common carotid artery.)
HEAD
Divided
clavicle
Left IJV
Left innominate v
Left SCV
Aortic arch
Left SCA
Divided sternum
Fig. 16.16. Satisfactory exposure of the left subclavian artery may require a combination of a median sternotomy with a left clavicular incision (inset). Note the
junction of the left internal jugular and left subclavian vein to form the left innominate vein. (IJV ¼ internal jugular vein, SCV ¼ subclavian vein.)
134
Exposure of the descending thoracic aorta Identify and protect the right vagus nerve, as it crosses over
the subclavian artery.
Optimal exposure is achieved through a generous left
posterolateral incision through the fourth intercostal space. In selected patients with small partial tears in the vessel,
primary repair is often possible. Use a 4–0 polypropylene
During dissection and isolation of the aorta, the esophagus
suture for a lateral arteriorrhaphy.
should be identified and protected. It lies on the right side
of the aorta, but as it enters the diaphragm it courses in In most cases with gunshot wounds or blunt injury to the
innominate artery, repair using the bypass exclusion
front of the aorta.
technique is required.
The left vagus nerve courses over the aortic arch, between
the subclavian and left common carotid arteries. In Gently palpate the aortic arch to determine suitability
proximal dissections it should be isolated and protected. for clamping. A side biting clamp is applied just
proximal to the innominate take off. Resect the injured
artery and examine the intima in the proximal end. If
Management of mediastinal venous injuries the intimal disruption extends into the aortic arch, this
Ligation of the innominate vein is usually well tolerated. area is not suitable for proximal graft placement.
Transient arm edema is the most common complication. If unable to use the proximal end of the innominate
Repair of the vein should be considered only if it can be artery, place the clamp on the proximal intrapericardial
done with lateral venorrhaphy and without stricture ascending aorta using a side-biting C clamp. Make an
formation. For an acute injury, especially in the aortotomy with an 11-blade.
hemodynamically compromised patient, complex Select an 8–10 mm low-porosity knitted polyester graft
reconstruction with synthetic grafts should not be and bevel it appropriately to avoid an acute right angle
performed. at its origin. This graft is then placed from the
Ligation of the SVC is not compatible with life because of ascending aorta to the distal innominate artery
the development of massive brain edema. Repair or immediately proximal to the bifurcation of the
reconstruction should always be attempted.
Intraoperative air embolism is a common and potentially (a)
lethal complication because of the negative venous
pressures in the severely hypovolemic patient. Early HEAD
occlusion of the venous tear by compression or application
of a vascular clamp helps to prevent this complication.
Management of mediastinal arterial injuries

Many patients with injuries to the major mediastinal arteries
arrive in extremis. However, ligation of these vessels is not
advisable because it may not be compatible with life and is
associated with a high incidence of limb loss. Simple suture
repair is the preferred choice whenever possible, and is often
the case with stab wounds. For more complex injuries with
tissue loss, usually due to gunshot wounds or blunt trauma, a
more complex reconstruction with prosthetic conduit may be
required. Damage control procedures, using a temporary Innominate
intravascular shunt, is ideal for all injuries involving the artery
branches of the aortic arch. However, for injuries involving
the aorta, shunting is not technically possible. In these cases,
temporary bleeding control and cardiopulmonary bypass may
be the only options.
Innominate artery or proximal right carotid artery

Identify the origins of the right subclavian and right
common carotid arteries and isolate with vessel loops and
vascular clamps for control. Extension of the sternotomy
into a right sternocleidomastoid incision is often necessary
in order to achieve good exposure of the right carotid
artery.
135
Fig. 16.17(a),(b). Repair of a simple injury (circle) of the innominate artery
with continuous suture.
Section 5: Chest
(b)
(b)
HEAD HEAD
Right lung
(c)
Fig. 16.17(a),(b). (cont.)
(a)
HEAD
Left CCA
Innominate
artery
Fig. 16.18(a),(b),(c)
Aorta
subclavian and right carotid arteries. The anastomosis

should be performed using a running 4–0
polypropylene suture.
Restore flow first to the subclavian artery, then to the
carotid artery.
Once the bypass is complete, oversew the proximal
innominate artery stump with a 4–0 polypropylene
suture.
Fig. 16.18(a),(b),(c). Repair of complex injury of the innominate artery with a
synthetic graft. A vascular clamp is applied on the proximal innominate artery, at its
junction with the aortic arch (a). An interposition size 8 synthetic graft is placed (b),(c).
136
Proximal left carotid artery Descending thoracic aorta

Proximal exposure is excellent through a median Placement of a double-lumen tube and deflation of the left
sternotomy. However, a standard left sternocleidomastoid lung upon entering the chest cavity improve the exposure
incision may be necessary for adequate distal control. of the thoracic aorta.
Damage control with a temporary arterial shunt is a good The lung is retracted and the posterior mediastinal
option for patients in extremis. This approach may not be structures come into view.
technically feasible for very proximal injuries. The first step is to obtain proximal control. This is
Primary repair is possible for most stab wounds. facilitated by first palpating and isolating the left
Reconstruction with saphenous vein or synthetic graft is subclavian artery, and tracing it back to the aortic arch.
required in most cases after gunshot wounds or blunt Identify and protect the left vagus nerve during the
trauma. In any complex reconstruction, temporary shunting dissection.
should be utilized to reduce the risk of ischemic stroke. Once the proximal aorta is identified, place a finger
carefully between the left carotid and left subclavian artery,
around the aorta to create a proximal clamping site. Place
umbilical tape around the aorta to facilitate clamp
Proximal subclavian artery placement.
Exposure and repair of the proximal right and left Once the proximal dissection is complete, obtain distal
subclavian arteries require combined sternotomy and control. Locate the aorta distal to the hematoma or the
clavicular incisions. bleeding site and incise the pleura over it. Encircle the aorta
Damage control with a temporary arterial shunt is a good with finger dissection followed by an umbilical tape. The
option in patients in extremis. This approach may not be dissection of the aorta should be limited to avoid avulsion
technically feasible for very proximal injuries. of the intercostal vessels.
Ligation of the subclavian artery should not be considered as When everything is ready to complete the repair, apply the
an acceptable method of damage control because of the high vascular clamps. Start with the proximal aortic clamp,
incidence of limb ischemia and compartment syndrome. followed by the distal aortic clamp, then secure the
Primary repair is possible for most stab wounds. However, subclavian artery with a vascular clamp or Rummel
reconstruction with a size 6–8 mm PTFE graft is required tourniquet.
in most gunshot wounds or blunt injuries (see chapter 9).
(a) Fig. 16.19(a)–(c). Proximal and distal control of

the descending thoracic aorta. Proximal dissection
and identification of the origin of the left subclavian
Phrenic nerve artery, which is encircled with a vessel loop (white
loop). Identify and protect the left vagus nerve
Left vagus nerve (yellow loop) (a). The pleura over the distal thoracic
HEAD aorta is dissected and the aorta is encircled (b).
Aorta
HEART
rta Left SCA

ao
i ng
end
sc
Left pulmonary hilum De
(Lung removed)
137
Section 5: Chest
(b) Fig. 16.19(a)–(c). (cont.)
RLN
Heart HEAD
Left SCA
Descen
ding ao
rta
Left vagus nerve
Incised pleura
(c)
Left phrenic n
HEAD
Proximal control
Diaphragm
Heart
Distal control
Rommel
Descending aorta
tourniquet
Left vagus nerve
Fig. 16.20. Repair of a simple laceration of the

descending aorta with a transverse continuous
suture, after proximal and distal control (circle).
HEAD
Left pulmonary hilum Left SCA
Diaphragm (Lung removed)
Heart
Left vagus nerve

Descending aorta
138
Left CCA Tips and pitfalls

The most serious and common error is performing the
Innominate artery operation without excellent knowledge of the local
anatomy.
Left subclavian artery
Using a double-lumen tube is not mandatory, but will
facilitate exposure and repair of the injury.
Perform the posterolateral thoracotomy through the
fourth intercostal space. Choosing the wrong space
makes exposure difficult. If exposure using the fourth
intercostal space is still inadequate, cut a rib above or
below the initial incision.
After a clamshell incision, both internal mammary arteries
are transected. Identify and ligate all four arterial ends.
There is a significant risk of air embolism in venous
injuries. In a hypovolemic patient it may take only a few
seconds. Control the venous injury by compression or
clamping as soon as possible.
Fig. 16.21. Repair of the descending aorta with an interposition graft, after
proximal and distal control. The left innominate vein lies under the thymus remnant
and surrounding fat. There is a risk of accidental injury
After the proximal and distal dissections are complete, the to the vein during the exploration of the upper
area of the aortic injury is dissected and the extent of the mediastinum.
damage assessed. Small penetrating injuries may be There is a risk of iatrogenic injury to the left vagus nerve, as
repaired with primary repair (4–0 or 5–0 polypropylene it crosses over the aortic arch, between the left carotid and
sutures). left subclavian artery, during dissection for proximal aortic
Complex injuries or injuries with extensive intimal control.
involvement will require an interposition graft. Identify the During innominate artery reconstruction, restoring blood
ends of the aorta and excise to healthy tissue. Look for flow to the carotid artery prior to the subclavian artery
bleeding from the intercostals; if identified, oversew with could potentially send debris or air to the brain rather than
4–0 polypropylene sutures. to the arm.
Sew proximal graft in first using a double-armed 4–0 Attempting to obtain proximal aortic control distal to the
polypropylene running suture without pledgets. Once the subclavian artery may make the repair difficult, with a very
proximal anastomosis is completed, stretch and cut the short proximal aorta on which to sew the graft. Obtaining
graft to an appropriate length and perform the distal control distal to the left carotid and proximal to the left
anastomosis. Just prior to completion of the distal subclavian provides extra room for repair.
anastomosis, release the distal clamp to check hemostasis Be careful while dissecting the distal aorta away from the
and to de-air the aorta. Complete the distal anastomosis vertebral column. Stay between the intercostal vessels and
and remove the proximal clamp. minimize superior and inferior dissection to prevent
Once hemostasis is achieved, cover the graft by closing the bleeding and avulsion of the intercostal vessels.
mediastinal pleura with absorbable sutures to exclude the When dissecting out the distal aorta, be sure to palpate and
graft from the lung. protect the esophagus to prevent injury and avoid
Place chest tubes and close the thoracotomy incision. including the esophagus in the distal aortic clamp.
139
Section 5 Chest
Lung injuries
Chapter
17 Demetrios Demetriades and Jennifer Smith
Surgical anatomy to alveoli where gas exchange occurs. These vessels are
large in diameter, but supply blood in a low pressure
The trachea divides into the right and left main bronchi at system.
the level of the sternal angle. The right bronchus is wider,
The bronchial arteries arise directly from the thoracic
shorter, and more vertical compared to the left. The right
aorta. These vessels are smaller in diameter, and supply the
bronchus divides into three lobar bronchi, supplying the
trachea, bronchial tree, and visceral pleura.
right upper, middle, and lower lung lobes, respectively. The
left bronchus divides into two lobar bronchi, supplying the The venous drainage of the lungs occurs via the pulmonary
left upper and lower lobes. veins. They originate at the level of the alveoli. There are
two pulmonary veins on the right and two on the left.
The lung has a unique dual blood supply. The pulmonary
These four veins join at or near their junction with the
arteries originate from the right ventricle. The right
left atrium, usually within the pericardium. These veins
pulmonary artery passes posterior to the aorta and superior
carry oxygenated blood back to the heart for distribution
vena cava. The left pulmonary artery courses anterior to
to the systemic circulation.
the left mainstem bronchus. The pulmonary arteries supply
deoxygenated blood from the systemic circulation directly The lung is covered superiorly, anteriorly, and posteriorly
by pleura. At its inferior border, the investing layers come
(a) into contact forming the inferior pulmonary ligament that
connects the lower lobe of the lung, from the inferior
pulmonary vein to the mediastinum and the medial part of
Left main the diaphragm. It serves to retain the lower lung lobe in
bronchus position.
Pulmonary artery (b)
Superior PV Left bronchus

PA
Inferior PV
Superior PV
Inferior PV
Inferior pulmonary
ligament
Fig. 17.1(a)–(d). Anatomy of the left hilum. The pulmonary artery is the Posterior Anterior
superior most structure within the pulmonary hilum. Note the close relationship
between the inferior pulmonary vein and inferior pulmonary ligament. Caution
should be taken to avoid injury to the vein during division of the ligament.
Fig. 17.1(a)–(d). (cont.)
140
Chapter 17. Lung injuries
(c) Fig. 17.1(a)–(d). (cont.)
PA
Superior PV
Left bronchus
Inferior PV
(d)
Pulmonary artery
Superior pulmonary
vein
Left bronchus
Heart
Inferior pulmonary
vein
Left
diaphragm
141
Section 5: Chest
(a) (a)
Right bronchus
Heart
Pulmonary artery
Superior pulmonary
vein Inferior pulmonary
ligament
Inferior pulmonary
vein
Left lower
lung lobe
Left diaphragm
(b)
(b)
Right bronchus
Inferior pulmonary
Right pulmonary vein
artery
Superior pulmonary
vein
Inferior pulmonary Divided inferior

vein pulmonary ligament
Fig. 17.3(a),(b). The inferior pulmonary ligament (a) connects the lower lobe
of the lung, from the inferior pulmonary vein to the mediastinum and the
medial part of the diaphragm. During division of the ligament, accidental injury
Fig. 17.2(a),(b). Anatomy of the right hilum. There are two structures located to the vein may occur (b).
anteriorly; the pulmonary artery superiorly, and the superior pulmonary vein
inferiorly. The posterior most structure is the right main stem bronchus. The
inferior-most structure is the inferior pulmonary vein.
General principles
Lungs have high blood flow, but are part of a low pressure
system. In addition, the lung tissue is rich in tissue
thromboplastin. This combination results in spontaneous
hemostasis from the lung parenchyma in the majority of
cases. Hilar or central lung injuries are the most common
cause of massive lung hemorrhage requiring operative
management.
About 80%–85% of penetrating and more than 90%
of blunt trauma to the lungs can safely be managed with
thoracotomy tube drainage and supportive measures alone.
Lung-sparing non-anatomical lung resections are preferable
to more extensive anatomical resections after injury.
Pneumonectomy after trauma is associated with very high
mortality.
142
Special surgical instruments injuries. In trauma, non-anatomical lung-sparing resections

are preferred over extensive anatomical resections.
The surgeon should have readily available a standard vascular
tray, Finochietto retractor, Duval clamps, Allison lung
retractor, and a sternal saw or Lebsche knife. Pneumonorrhaphy
This technique is used to repair small, superficial lung
Anesthesia considerations injuries. Following careful individual suture ligation of any
If the hemodynamic condition of the patient allows, insert major bleeders and air leaks, the laceration is repaired with
a double-lumen tube. figure-of-eight absorbable sutures, on a large tapered
Maintain low tidal volumes to reduce the risk of air embolism. needle. Application of tissue glue prior to approximation of
the edges of the laceration may improve hemostasis and
Positioning control minor air leaks.
In cases with bleeding and air leaks from deep penetrating
The patient is placed supine on the operating room table with
lung injuries, suturing of the entry and exit wounds should
both arms abducted to 90 degrees. Skin preparation should
be avoided because of the risk of air embolism,
include the neck, anterior and bilateral lateral chest walls, and
intrapulmonary hematoma, and hemorrhagic flooding of
the abdomen down to the groin.
(a)
Incisions
Median sternotomy
It is the incision of choice in penetrating injuries to the anter-
ior chest with suspected cardiac or anterior mediastinal vascu-
lar injuries. It provides good exposure of the heart, the anterior
mediastinal vessels, both of the lungs, the middle and distal
trachea, and left mainstem bronchus. It is quick to perform,
relatively bloodless, and causes less postoperative pain and
fewer respiratory complications than a thoracotomy. However,
it does not allow for good exposure of the posterior medias-
tinal structures and does not provide adequate access for cross-
clamping of the thoracic aorta for resuscitation purposes. The
technique is described in Chapter 14.
It is the preferred incision in cases with lung injuries. The
technique is described in Chapter 14. (b)
Clamshell thoracotomy
It is usually performed as an extension of a standard antero-
lateral thoracotomy to the opposite side, for suspected bilateral
lung injuries, superior mediastinal vascular injuries or cardiac
resuscitation, and for aortic cross-clamping purposes. The
technique is described in Chapter 14.
Operative techniques
The type of lung operation is determined by the site and
severity of lung injury, the shape and direction of the lung
wound, the hemodynamic condition of the patient, and the
experience of the surgeon. The operative techniques may
include suturing of the bleeding lung, lung tractotomy,
wedge resection, lobectomy, and total pneumonectomy.
There is a stepwise increase in both mortality and
complications with more extensive resections. This is Fig. 17.4(a),(b). Peripheral stab wound to the lung, amenable to primary
independent of injury severity and the presence of associated repair. Pneumonorrhaphy with figure-of-eight repair.
143
Section 5: Chest
the bronchial tree, including the contralateral lung. These suture ligated under direct visualization. Application of
cases should be managed with lung tractotomy or tissue glue may be helpful in decreasing any diffuse
segmental resection. bleeding and minor air leaks. The tract may be closed with
figure-of-eight absorbable sutures on a large tapered
needle.
Lung tractotomy On rare occasions, tractotomy may devascularize
This is the procedure of choice in cases with bleeding and/or segments of the lung, resulting in subsequent ischemic
major air leaks from deep, penetrating injuries. Tractotomy necrosis and lung abscess. The tractotomy should be
is not indicated in suspected hilar injuries. These injuries performed parallel to the vascular supply whenever
usually require lobectomy or total pneumonectomy. possible. The lung adjacent to the tractotomy should
The wound tract is opened with a GIA stapler with a always be assessed for viability and any questionable tissue
2.5 mm white load. Any significant bleeders or air leaks are should be resected.
(b)
(a)
(c) (d)
Fig. 17.5(a)–(d). Technique of stapled tractotomy in a through-and-through penetrating injury to the lung (a). Placement of a GIA stapler through the wound (b).
Opened tract after tractotomy (c). Oversewing of bleeders and areas of air leak in the tract (d).
144
(a)
Heart
Left
diaphragm
Fig. 17.6. Devascularized and dead lung tissue after tractotomy. To prevent
this complication, the tractotomy should be parallel to the vessels.
Wedge resection
(b)
For larger peripheral injuries, the injured lung may be resected
non-anatomically. Using a GIA stapler with a 2.5 mm white
load, “wedge out” the injured tissue. Any persisting bleeding or
air leaks can be managed with additional sutures and/or tissue
glue. Alternatively, if a stapling device is not available, the
injured tissue may be placed between clamps and the tissue
“cut out.” The edges are then oversewn using a running
technique.
Non-anatomic lobe resection

After temporary bleeding control with digital compression
or application of a vascular clamp around the hilar
structures, the hilar vessels are dissected free and the injury
is identified. Depending on the anatomical location of the
injury, the need for a lobectomy or pneumonectomy is
determined.
Anatomic lobe resection is rarely used in trauma and has
been replaced by non-anatomical resection, preserving as (c)
much normal lung parenchyma as possible.
During lower lobe resections, the inferior pulmonary
ligament should be divided.
The resection is best accomplished using a TA stapling
device. Before release of the stapler, two stay sutures or
Allis forceps are applied to the stump in order to prevent
retraction. Once the stapler is released, the suture line can
be held using the stay suture to inspect for, and control, any
bleeding or air leaks.
During the procedure, care should be taken to avoid
devascularization of the remaining normal lung
parenchyma.
After resection of the lower lobe, avoid torsion of the
remaining upper lobe. Failure to recognize this problem
results in ischemic necrosis of the normal lobe. The
remaining lung parenchyma can be tacked into place using
superficially placed 3–0 sutures on a tapered needle.
Fig. 17.7(a)–(c). Wedge resection of lung parenchyma using a GIA stapler
after a peripheral stab wound.
145
Section 5: Chest
(a) (a)
Heart Left lung
Right lung
Hilum
Left diaphragm
(b)
LUL
(b) Heart
Right lung
(c)
Hilum
Fig. 17.8(a),(b). Temporary bleeding control with digital compression of the

right lung hilum (a). Application of vascular clamp around the left hilum (b).
Fig. 17.9(a)–(c). Dissection of the left hilar vessels to determine the need for
lobectomy or total pneumonectomy (a). En-masse stapled left lower lobectomy.
If necessary, additional sutures may be placed for better hemostasis (circle
shows the stump, arrow shows the stay suture to prevent retraction of the
stump and check for hemostasis or air leaks). Stapled left lower lobectomy
146 specimen (c).
(a)
Heart
Hilum
Left
lung
Fig. 17.10. Torsion and ischemic necrosis of the normal upper lobe following
lower lobectomy. Left
diaphragm
Pneumonectomy
(b)
A total pneumonectomy may be necessary in severe hilar
injuries not amenable to repair or lobectomy.
In hilar vascular injuries the patient is usually
hemodynamically unstable and there is severe active bleeding.
The fastest way to achieve temporary bleeding control is
digital compression of the hilum and subsequent application
Left
of a vascular clamp, as described above. This maneuver is
lung
critical for effective bleeding control, and prevention of air Heart
embolism and hemorrhagic flooding of the normal bronchial
tree. Acute occlusion may aggravate the hemodynamic
condition of the patient because of acute right-sided cardiac
strain. An alternative to clamping the hilum is to perform a
“hilar twist” after release of the inferior pulmonary ligament.
The whole lung is twisted 180o around the hilum.
Pneumonectomy normally involves individual isolation,
ligation, and division of the hilar structures. However, this
approach is time-consuming and requires significant Left
technical skills and experience. In the decompensated diaphragm
trauma patient, an acceptable alternative to the anatomical
pneumonectomy is the en-masse stapled pneumonectomy.
Fig. 17.11(a),(b). Hilar twist for temporary control of hilar bleeding. After
The en-masse pneumonectomy can be rapidly performed division of the inferior pulmonary ligament to free the lung, the lung is grasped
using a TA stapler. in its entirety and rotated 180° in a clockwise direction.
The main bronchus should be divided as close to the
carina as possible to avoid pooling of secretions and to
reduce the risk of breakdown of the stump. stapler is released. This prevents retraction of the stump
Following division of the inferior pulmonary ligament, after the removal of the stapler and facilitates
the hilum is isolated and the index finger is placed identification and control of any bleeding or air leaks.
around it. Buttressing of the stump with adjacent tissues, such as
After application and firing of the TA stapler around all the pericardial fat pad, parietal pleura, or intercostal
hilar structures, the vessels and bronchus are divided muscle flap may be used.
approximately 0.5 cm above the instrument. Total pneumonectomy is associated with a very high
Two figure-of-eight stay sutures or two Allis forceps are mortality, usually due to hemorrhage or acute right cardiac
placed at the two corners of the stump, before the failure.
147
Section 5: Chest
(a) (c)
Heart
Hilum
Left
lung
Left
diaphragm
Left
diaphragm
Left lung
(b)
(d)
Heart
Hilum
Hilar stump
Allis forceps
Left lung
Fig. 17.12(a)–(e). (cont.)
Fig. 17.12(a)–(e). Technique of en-masse stapled left total
pneumonectomy. The hilum is isolated and the index finger is placed
around it (a). A TA stapler is placed around all the structures of the pulmonary
hilum (b). Division of all hilar structures with scalpel, about 0.5 cm above the
stapler (c). Placement of two stay sutures or Allis forceps on the stump before
removal of the stapling device to prevent retraction of the stump (d). Any
bleeding or air leaks can be controlled with additional figure-of-eight
absorbable sutures (e).
148
(e)
Heart
Left
Hilar stump
diaphragm
Fig. 17.12(a)–(e). (cont.)
Closure
The techniques of sternotomy or thoracotomy closure are
described in Chapter 14.
Complications
Air embolism
This is a potentially lethal complication and may occur in
deep penetrating or hilar injuries involving both the Fig. 17.13. Massive air embolism with air bubbles seen in the coronary veins (circles).
bronchial tree and the pulmonary veins.
Suturing of the entry and exit wounds of a deep tract During lung tractotomy or non-anatomic resection,
creates the ideal conditions for air embolism and should portions of the residual lung may become ischemic and
never be done. The appropriate procedure is a tractotomy necrotic. Orient the tractotomy or resection lines parallel to
or a resection. the vessels and check the residual lung for viability.
Air embolism should be suspected when the patient During stapled lobectomy or total pneumonectomy, the
develops arrhythmias or cardiac arrest. Sometimes, air hilar stump retracts and can make identification of any
bubbles may be seen in the coronary veins. persistent bleeding difficult. This may be life threatening if
In suspected air embolism the patient is placed in the the stapler misfires. Never release the stapling device before
Trendelenberg position, the apex of the heart is elevated placement of two stay sutures or Allis forceps on the stump.
and both ventricles are aspirated. Anatomic lung resections have limited or no role in trauma.
Perform non-anatomic, lung-preserving resections.
During division of the inferior pulmonary ligament, there is a
Right heart failure risk of injury to the inferior pulmonary vein. Proceed cautiously
This occurs when a large volume of lung parenchyma is and divide only the semi-transparent part of the ligament.
removed acutely. The volume of blood is now distributed After major lung resections it is essential to reduce the tidal
over a smaller volume of parenchyma. This complication volume accordingly. Also, restrict fluid administration
requires careful fluid status titration and cardiac output because many patients develop acute right cardiac failure.
support with the use of inotropes. This is a common cause of postoperative death.
After major lung operations, perform a bronchoscopy
Tips and pitfalls routinely to aspirate any blood from the remaining and
Suturing of the entry and exit wounds of a deep tract contralateral bronchial tree.
creates the ideal conditions for air embolism and should The main bronchus should be divided as close to the carina
never be done. The appropriate procedure is a tractotomy as possible to avoid pooling of secretions and reduce the
or a resection. risk of breakdown of the stump.
149
Section 5 Chest
Thoracic esophagus
Chapter
18 Daniel Oh and Jennifer Smith
Surgical anatomy The thoracic duct lies between the esophagus, the
The esophagus is approximately 25 cm in length and begins aorta and the azygos vein before crossing over, just
at the level of the C6 vertebra. The external landmark is the below the level of the tracheal bifurcation, to the
cricoid cartilage. It terminates 2–3 cm below the left hemithorax where it drains into the left
diaphragmatic hiatus, which corresponds to the T11 vertebra. subclavian vein.
The esophagus is divided into three parts: cervical, The esophagus does not have a serosal layer.
thoracic, and intra-abdominal. The cervical esophagus The arterial and venous blood supply and drainage of the
begins approximately 15 cm from the upper incisors and is esophagus are segmental. The cervical esophagus is
approximately 6–8 cm long. The thoracic esophagus begins supplied by branches of the inferior thyroid artery. The
approximately 23 cm from the incisors and is upper thoracic esophagus is supplied by the inferior
approximately 15 cm in length. The intra-abdominal thyroid artery and an anterior esophagotracheal branch
esophagus begins approximately 38 cm from the incisors at directly from the aorta. The middle and lower esophagus
the diaphragmatic hiatus and extends for 2–3 cm distally receives its arterial supply directly from the aorta via a
before becoming the gastric cardia. bronchoesophageal branch. The lower esophagus and
The thoracic esophagus rests on the thoracic spine and the intraabdominal esophagus portions are supplied by small
longus colli muscles. It passes posterior to the trachea, the branches from the left gastric artery and the left inferior
tracheal bifurcation, the left main stem bronchus, and the phrenic artery.
left atrium. It descends to the right of the thoracic aorta The parasympathetic innervation of the esophagus is
and moves anterior to the aorta, just above the diaphragm. through the vagal nerves. The right and left recurrent
The azygos vein lies in front of the bodies of the lower laryngeal nerves travel in the tracheoesophageal groove,
thoracic vertebrae and to the right of the esophagus. At the giving off branches to both the trachea and the cervical and
level of the bifurcation of the trachea, it arches anteriorly to upper esophagus. The vagal nerves join with the fibers of
drain into the superior vena cava, just before it enters the the sympathetic chain to form the esophageal plexus.
pericardium. Together with the esophagus, the vagi pass through the
The hemiazygos vein passes from the left side of the spine diaphragm and continue along the lesser curvature of the
to the right, after crossing the spine and traveling in front stomach.
of the aorta and behind the esophagus and thoracic duct, to The sympathetic innervation comes from the cervical and
drain into the azygos vein. thoracic sympathetic chains.
150
Chapter 18. Thoracic esophagus
(a)
(b)
Posterior
wall of the
trachea
Fig. 18.1(a). Anatomy of the esophagus and its Fig. 18.1(b). Anatomical relationship between the cervical and upper thoracic esophagus and the larynx
relationship with the spine, trachea, and and trachea.
thoracic aorta.
151
Section 5: Chest
General principles Place drains adjacent to the repair.

Consider placement of a draining gastrostomy tube and a
Most esophageal injuries can be repaired with suturing or a
jejunostomy tube for nutritional support.
limited resection and primary anastomosis. In rare cases
with extensive soft tissue loss or delayed diagnosis it may
be necessary to perform resection and reconstruction with Special surgical instruments
gastric pull up or colon interposition. These complex General thoracic tray (Allison lung retractor, Bethune rib
procedures will not be discussed in this chapter. shears, Duval lung forcep, Davidson scapula retractor,
Primarily repair the mucosa with absorbable interrupted Finochietto retractor)
sutures. 100 Penrose drain, thoracotomy tubes
The primary repair or anastomosis should be tension-free Head light
and the edges viable and adequately perfused. Important
technical principles for primary repair include the
following. Anesthesia considerations
Debride all injured, ischemic, and necrotic or infected Single lung ventilation is critical for exposure of the
tissue. thoracic esophagus.
Incise the muscular layer longitudinally superiorly and
inferiorly to the injury to expose the entire extent of the
mucosal injury. Primarily repair the mucosa with
Patient positioning
absorbable interrupted sutures. Upper and middle thoracic esophageal injuries: left lateral
decubitus (right side up)
Repair the muscularis layer with interrupted non-
absorbable sutures. Lower thoracic esophageal injuries: right lateral decubitus
(left side up)
Avoid narrowing the esophageal lumen.
Reinforce the primary repair with well-vascularized
adjacent tissue flaps.
152
Supine for patients undergoing a laparotomy for intra- (a)

abdominal esophageal injuries.
For lateral decubitus positioning, ensure the following:
An axillary roll is placed in the axilla.
Penis and testes are not compressed.
Padding is placed between the knees.
Fig. 18.2. Positioning of patient for a right posterolateral thoracotomy.
Incisions
Choice of incision depends on the location of the injury. Fig. 18.3(a),(b). The skin incision for a posterolateral thoracotomy extends
from the anterior axillary line, coursing about one to two finger breadths below
Cervical esophagus: standard left neck incision along the the tip of the scapula, and extends posteriorly and cephalad midway between
sternocleidomastoid muscle (see Chapter 7). the spine and the medial border of the scapula.
Upper and middle thoracic esophagus: right
posterolateral thoracotomy in the fifth or sixth
intercostal space. Divide the subcutaneous tissue. Identify and divide the
Lower thoracic esophagus: left posterolateral latissimus dorsi muscle, but can preserve the rhomboid
thoracotomy in the seventh or eighth intercostal muscle posteriorly. This muscle can be avoided by
space. locating the “empty triangle” between the two muscle
groups.
Intra-abdominal esophagus: laparotomy.
Use the scapula retractor and palpate the number
of rib spaces.
Divide the intercostal muscle from its insertion site on the
Standard posterolateral thoracotomy superior border of the sixth rib to avoid the neurovascular
Identify the scapula border and mark the skin. bundle coursing along the inferior rib border.
The skin incision for a posterolateral thoracotomy extends Remove a 2 cm segment of rib using the Bethune
from the anterior axillary line, coursing about 1–2 finger rib shears in order to prevent rib fracture during
breadths below the tip of the scapula, and extends Finochietto retractor placement. If further exposure
posteriorly and cephalad midway between the spine and is needed, a subtotal rib resection may be done.
the medial border of the scapula. Place the Finochietto retractor.
153
Section 5: Chest
(b)
RIGHT
SHOULDER
Tip of the scapula
Incision
Spine
Fig. 18.3(a),(b). (cont.)
Latissimus
dorsi muscle
RIGHT
SCAPULA
Ribs and
intercostal muscles
Fig. 18.4. Exposure of the latissimus dorsi muscle. Note the “empty triangle”
(arrow), which separates the latissimus from the more posterior rhomboid
muscle.
Fig. 18.5. Cephalad retraction of the scapula exposes the underlying ribs
and intercostal spaces (the tip of the scapula is usually over the sixth or seventh
intercostal space).
154
(a) (c)
Fig. 18.6(a). Division of the intercostal muscle at its insertion on the superior
border of the rib (arrows) to avoid the neurovascular bundle, which is located at
the inferior border of the rib.
Fig. 18.6(c). Removal of 2 cm segment of the rib (circle) in order to prevent

(b) rib fracture during Finochietto retractor placement.
Exposure of the thoracic esophagus

The upper and middle thoracic esophagus is exposed through
a right posterolateral thoracotomy, as described above.
Divide the inferior pulmonary ligament and retract the
right lung anteriorly.
Visualize the mediastinal pleura and inspect for violation
or injury. Evacuate debris and devitalized tissue.
The azygos vein will be seen coursing across the
esophagus toward the superior vena cava.
Open the posterior mediastinal pleura overlying the
esophagus, along the length of the azygos vein.
If necessary for exposure, ligate and divide the azygos
vein as it crosses the esophagus.
Fig. 18.6(b). Limited mobilization of the sixth rib to prepare for excision Mobilize the esophagus and place a Penrose drain
(circle). around it.
155
Section 5: Chest
(a) Fig. 18.7(a). Posterior mediastinum with

retraction of the right lung anteriorly. The azygos
HEAD vein is seen coursing over the esophagus (white
arrow), toward the superior vena cava (SVC). The
posterior mediastinal pleura overlying the
esophagus is incised.
Esophagus
Incised pleura
Azygos vein
(b) Fig. 18.7(b). Ligation and division of the azygos

vein (white arrow), improves the exposure of the
HEAD underlying esophagus.
Retracted right lung
Esophagus
156
(c)
HEAD
HEAD
Divided
Esophagus azygos vein
Fig. 18.8. A Penrose drain is placed around the esophagus for retraction.
Repair of the esophagus

Identify the injury and mobilize the esophagus above and
Fig. 18.7(c). Exposure of the esophagus after division of the azygos vein
below. Take care not to devitalize the esophagus during
(arrows show the divided ends of the azygos). mobilization. Open the muscle fibers longitudinally to fully
expose the extent of the mucosal injury.
Repair the mucosa with interrupted absorbable sutures.
Repair the muscle layer with interrupted non-absorbable
The lower third of the esophagus is exposed through a left sutures.
posterolateral thoracotomy, as described above. Create a flap from the parietal pleura on the chest wall and
secure it over the esophageal repair.
Divide the inferior pulmonary ligament and retract the
left lung anteriorly. Additionally or in lieu of the pleura, an intercostal muscle
flap with its neurovascular bundle may be mobilized from
The esophagus is located to the right of the thoracic
an adjacent interspace and brought over the esophageal
aorta and can easily be palpated after placement of a
repair for additional coverage. Alternatively, a pericardial
nasogastric tube.
fat-pad flap can be used.
Incise the pleura over the esophagus, mobilize, and
The wound is copiously irrigated and drained using
place a Penrose drain around it.
standard chest tubes.
If not placed previously, a nasogastric tube is guided past
the site of repair and into the stomach, taking care to avoid
damaging the repair site.
A jejunostomy feeding tube can be inserted through a
mini-laparotomy at the time of the esophageal repair.
157
Section 5: Chest
(a) (b)
HEAD HEAD
Mucosa
Fig. 18.9(b). The esophageal muscle fibers (white arrows) are opened
longitudinally to fully expose the extent of the mucosal injury (black arrows).
Fig. 18.9(a). Identification of the esophageal perforation (circle).
158
(a) (c)
HEAD HEAD
Fig. 18.10(a). The mucosa is repaired with an interrupted absorbable suture

(white arrows). Muscularis layers are retracted by forceps (black arrows).
(b)
HEAD
Fig. 18.10(c). The muscle layer is repaired with an interrupted

non-absorbable suture (circle).
Muscle layer
Mucosal repair
Fig. 18.10(b). Completed mucosal repair.
159
Section 5: Chest
(a) (b)
HEAD HEAD
Esophagus
Esophagus
Fig. 18.11(b). The pleural flap is sutured over the esophageal repair (circle).
Fig. 18.11(a). A flap (white arrow) from the parietal pleura is created and
brought over the esophageal repair.
(b)
(a)
Right scapula
Esophagus
Fig. 18.12(a). Creation of an intercostal muscle flap (white arrows) with its Fig. 18.12(b). Suturing of the muscle flap over the esophageal
neurovascular bundle from an adjacent intercostal space. repair (circle).
160
Exposure and repair of the intra-abdominal Tissue reinforcement options

esophagus Pleural flap, intercostal muscle flap, pericardial fat-pad flap.
A laparotomy is the approach used to repair an injury to
the intra-abdominal esophagus.
The left triangular ligament is divided and the liver is Tips and pitfalls
retracted. This exposes the esophageal hiatus. Delayed recognition and repair of the esophagus is associated
The short gastric vessels can be divided to aid with with a high incidence of infectious complications and death.
mobilization of the gastroesophageal junction for Cervical esophageal leaks usually cause an abscess or an
improved exposure of the injury. esophageal fistula and are rarely life threatening. However,
Following primary repair, the hiatus is closed with thoracic esophageal leaks can cause severe mediastinitis
interrupted non-absorbable sutures to recreate an and are often life threatening.
opening that only accommodates the esophagus and one Any repair or anastomosis should be tension free and well
fingertip. perfused.
A feeding jejunostomy tube is placed for postoperative Routine wide drainage of all esophageal repairs is critical.
alimentation. Use tissue flaps to reinforce the esophageal repair. This is
For destructive injuries, a circular stapled anastomosis particularly important in the presence of associated
placed through a gastrotomy is an acceptable tracheal injuries due to the risk of tracheoesophageal fistula
alternative. or vascular injuries due to the risk of arterioesophageal
fistula.
161
Section 5 Chest
Diaphragm injury
Chapter
19 Lydia Lam and Matthew D. Tadlock
Surgical anatomy Head

The diaphragm consists of a peripheral muscular segment
and a central aponeurotic segment. It is attached to the Sternum
lower sternum, the lower six ribs, and the lumbar spine.
During expiration, it reaches the level of the nipples. The
central tendon of the diaphragm is fused to the base of the
pericardium.
It has three major openings, which include the aortic Left costal margin
foramen which allows passage of the aorta, the azygos vein,
and the thoracic duct, the esophageal foramen for the Left nipple
esophagus and the vagus nerves and finally the vena cava
foramen, which contains the inferior vena cava.
The arterial supply stems from the phrenic arteries that
are direct branches off the aorta as it exits the hiatus,
while the venous drainage is directly into the inferior
vena cava.
The diaphragm is innervated by the phrenic nerve, which Fig. 19.1. Any asymptomatic penetrating injury in the left thoracoabdominal
area, between the nipple superiorly and the costal margin inferiorly, should be
originates from the C3–C5 nerve roots, courses over the evaluated laparoscopically to rule out diaphragmatic injury.
anterior scalene muscle, continues into the mediastinum
along the pericardium, and terminates in the diaphragm.
Special instruments
Equipment for the open operation would include a major
laparotomy tray. A Bookwalter retractor improves the
General principles exposure of posterior diaphragmatic injuries.
The diagnosis of an isolated, uncomplicated
diaphragmatic injury can be challenging because such Laparoscopic repair
injuries are often asymptomatic and the radiological Positioning
findings may be subtle. Untreated diaphragmatic injuries
will result in a diaphragmatic hernia, which can manifest The patient should be placed in the supine position.
long after the injury. This complication usually occurs on Once the laparoscope is inserted, the patient should be
the left diaphragm, although both sides are at risk. placed in reverse Trendelenberg and right decubitus to
improve visualization of the left diaphragm.
Any asymptomatic penetrating injury to the left
thoracoabdominal area, between the nipple superiorly and
the costal margin inferiorly, should be evaluated Incisions
laparoscopically to rule out diaphragmatic injury. Trocar placement should adhere to general laparoscopy
Repair of isolated diaphragmatic injuries can be performed principles of triangulation to allow access to likely areas of
laparoscopically or through a laparotomy. injury on the diaphragm. To begin, a standard supra-
umbilical trochar can be used to insert a camera for
162
Chapter 19. Diaphragm injury
diagnostic confirmation of the injury. Once the injury is (a)

localized, additional ports can be inserted to maximize
access to the injury.
Xiphoid
Umbilicus
(b)
Fig. 19.2. Trocar placement for diagnostic laparoscopy for diaphragm evaluation.
(a)
Diaphragm laceration with

omental herniation
Fig. 19.4(a),(b). Laparoscopic repair of diaphragm with figure-of-eight with

non-absorbable suture. It is important to grasp the diaphragm and pull toward
the camera for a good suture bite.
Repair
(b) Lacerations should be repaired with interrupted non-
absorbable sutures. Alternatively, laparoscopic hernia
staples may be used.
Diaphragm laceration with
omental herniation
Open repair
Positioning
Patient should be placed in the supine position with both
arms abducted.
A standard trauma preparation from the chin to the knees
is used as access to the chest may be necessary.
Liver
Incision
Fig. 19.3(a),(b). Diagnostic laparoscopy view of diaphragm injury with A standard midline laparotomy incision should be used for
omental herniation. repair of the diaphragm to enable a complete investigation
163
Section 5: Chest
of the remaining abdomen. For chronic injuries, a thoracic (a)

approach may be considered.
Exposure
Superior cephalad retraction of the costal margins is key to
adequate exposure of the diaphragm. The use of a fixed
retractor such as the Bookwalter retractor is strongly Liver
recommended.
The diaphragmatic wound edges are grasped with Allis
clamps and pulled anteriorly, to improve exposure and Spleen
repair. Clamps can be placed at the apices to line up the
edges of the laceration and facilitate suturing. This is Stomach
particularly important for posterior injuries, which are
difficult to access.
If there is a diaphragmatic hernia, reduce the contents with
gentle traction. If necessary, enlarge the diaphragmatic
defect to reduce incarcerated contents. Inspect contents for
any ischemic necrosis.
(b)
Repair Allis clamp

The diaphragmatic defect can be repaired with interrupted
figure-of-eight sutures, using number 0 or 1 monofilament,
non-absorbable sutures. Alternatively, for larger injuries, a
running suture can be used.
High-energy deceleration injuries can result in avulsion of
the diaphragm from its chest wall attachments. In these
instances, the diaphragm will need to be secured to the
chest wall. It may be necessary to perform an ipsilateral
thoracotomy to allow horizontal mattress sutures to be
placed around the ribs to secure the diaphragm in its
typical position. The use of synthetic meshes typically is
not necessary in the acute setting, as tissue loss and domain
loss have not had time to occur.
Prior to definitive closure, perform transdiaphragmatic
irrigation of the pleural cavity to minimize contamination, Fig. 19.5(a),(b). Posterior diaphragm laceration (circle) at laparotomy. Repair
may be difficult because of the deep location and poor exposure of the wound
especially in the presence of concomitant hollow viscus (a). The exposure can improve significantly by grasping the diaphragm injury
injuries. with a forceps and pulling it toward the umbilicus (arrow) (b).
A tube thoracotomy should always be placed after the
diaphragm repair.
Repair of posterior diaphragmatic wounds during
Tips and pitfalls laparotomy is difficult due to poor exposure. Improve
exposure by grasping the edges of the wound and pulling
In the presence of a diaphragmatic defect, there is a risk of the diaphragm towards the laparotomy incision.
tension pneumothorax during abdominal insufflation for
In the presence of peritoneal intestinal content
laparoscopy. Monitor closely the hemodynamic and
contamination there is an increased risk of empyema.
oxygenation status and peak inspiratory pressures. If any
Wash out the pleural cavity through the diaphragmatic
sign of tension pneumothorax develops, release abdominal
defect and remove any gross contamination.
insufflation and insert a chest drain.
Although rare, during repair of the diaphragm below the
In some cases laparoscopic repair may be difficult because
pericardium, place the sutures under direct visualization to
of the loss of pressure through the diaphragmatic defect
avoid inadvertent injury to the myocardium.
and into the chest drain. Grasping the edge of the wound
with a forceps and partially twisting it can occlude the After diaphragmatic repair, always place a thoracotomy
tube for postoperative drainage.
defect and allow repair.
164
Section 6 Abdomen
General principles of abdominal operations

Chapter
20 for trauma
Heidi L. Frankel and Lisa L. Schlitzkus
Surgical anatomy Zone 2 Zone 1 Zone 2 Fig. 20.1. Retroperitoneal

vascular zones: Zone I
The anterior abdominal wall has four muscles: the includes the midline
external oblique, the internal oblique, the transversalis, vessels from the aortic
and the rectus muscles. The aponeuroses of the first hiatus to the sacral
promontory; Zone II
three muscles form the rectus sheath, which encloses the includes the kidneys with
rectus abdominis muscle. the renal vessels; and
Zone III includes the
The linea alba is a midline aponeurosis which runs from pelvic retroperitoneum,
the xiphoid process to the pubic symphysis and separates with the iliac vessels.
the left and right rectus abdominis muscles. It is widest just
above the umbilicus, facilitating entry into the peritoneal
cavity.
For vascular trauma purposes, the retroperitoneum is
conventionally divided into four anatomic areas:
Zone I. Extends from the aortic hiatus to the sacral
promontory. This zone is subdivided into the
supramesocolic and inframesocolic areas. The
supramesocolic area contains the suprarenal aorta and
its major branches (celiac axis, superior mesenteric
artery (SMA), and renal arteries), the supramesocolic
inferior vena cava (IVC) with its major branches, and Zone 3
the superior mesenteric vein (SMV). The
inframesocolic area contains the infrarenal aorta
and IVC.
Zone II. Includes the kidneys, paracolic gutters, and General technical principles
renal vessels. A laparotomy for bleeding is different from a laparotomy
Zone III. Includes the pelvic retroperitoneum and for peritonitis.
contains the iliac vessels. The top priority of the surgeon is to stop the bleeding! This
Zone IV. Includes the perihepatic area, with the hepatic should be followed by a methodical exploration of all
artery, the portal vein, the retrohepatic IVC, and structures to identify and repair other non-life-threatening
hepatic veins. injuries.
Consider damage control early before major physiological
deterioration (coagulopathy, hypothermia, acidosis)
occurs. In determining the need for damage control, take
into account the nature of the injury, associated injuries,
the physiological condition of the patient, the hospital
capabilities, and the skillset of the surgeon.
Removal versus repair for organs such as the spleen and
kidney should be determined by the injury severity and
165
Section 6: Abdomen
physiologic condition of the patient. Splenectomy or

nephrectomy should be considered even in moderate
Positioning of patient and skin preparation
severity injuries if the patient is unstable. The patient should be placed in the supine position with
the arms abducted to 90 degrees.
If damage control packing does not stop the bleeding, do
not terminate the operation. Re-explore and look for If there is concern for rectal or anal canal injury, the patient
may be placed in lithotomy.
surgical bleeding.
The bed rails should be free and exposed for fixed surgical
In damage control procedures the abdomen should always
retractor placement.
be left open using temporary closure techniques in order
to prevent intra-abdominal hypertension or abdominal The patient should undergo a standard trauma preparation
compartment syndrome. from chin to knees and laterally to the bed. Inclusion of the
groins in the field is important because of the possibility of
the need of saphenous vein graft.
(a) Fig. 20.2(a),(b). Position and skin preparation for

trauma laparotomy. The patient should be prepped
from chin to knees and laterally to the bed
(posterior axillary lines).
(b)
166
Chapter 20. Abdominal trauma operations
Special instruments Head lights are strongly recommended.

An electrothermal bipolar vessel sealing system device
A trauma laparotomy set should include basic vascular
(LigaSure device) may be useful. It expedites division of the
instruments.
mesentery in cases requiring bowel resection. It is also a
A Bookwalter retractor or other fixed surgical retractor will
useful instrument for liver resections and splenectomy.
facilitate surgical exposure, especially in anatomically
difficult areas.
(a) Incisions
HEAD A full midline laparotomy is the standard incision in
trauma. The extent of the incision is determined by the
location of any penetrating injury and the condition of the
patient. The incision should be long enough to provide
comfortable exposure and allow a complete exploration of
the abdomen. A xiphoid to pubic symphysis incision
should be considered in hemodynamically unstable
patients with penetrating trauma and unknown missile
trajectories. The concept of routine xiphoid to pubic
symphysis incision in all trauma laparotomies is not
advisable.
In a hypotensive patient, the abdomen should be entered
quickly, without wasting time for local hemostasis. The
skin, subcutaneous tissue, and the linea alba are incised
sharply. The best place to incise the linea alba is 2–3 cm
above the umbilicus, where the aponeurosis is at its widest
part and where there is a reduced risk of entering the rectus
sheath. The preperitoneal fat is then swept away, and the
peritoneum is identified and entered. A finger can be used
to enter the peritoneal cavity just superior to the umbilicus
at the thinnest point.
(a)
HEAD
(b)
Preperitoneal fat
Linea alba
Fig. 20.4(a),(b). The skin, subcutaneous tissue, and the linea alba are
Fig. 20.3(a). Bookwalter retractor in place. (b) Electrothermal bipolar vessel incised. The preperitoneal fat is then swept away and the peritoneum is
sealing system device (LigaSure device). identified and entered.
167
Section 6: Abdomen
(b) (a)
HEAD
(b)
HEAD
Fig. 20.4(a),(b). (cont.)
In some cases with complex posterior liver or retrohepatic

major venous injuries, the exposure can be improved by
adding a right subcostal incision to the standard midline
laparotomy. The standard subcostal incision is made one to
two finger breadths below the costal margin. Avoid an
acute angle between the two incisions to prevent ischemic
Fig. 20.5(a),(b). Addition of a right subcostal incision to the standard midline
necrosis of the skin. The rectus abdominis, external laparotomy, for improved exposure of the liver. The subcostal incision is made
oblique, internal oblique, and transversalis muscles are one to two finger breadths below the costal margin. Avoid an acute angle
divided. between the two incisions to prevent ischemic necrosis of the skin.
Extension of the midline laparotomy into a median

sternotomy can be useful in cases with severe liver injuries
requiring atriocaval shunting or total liver vascular
isolation. The technique of median sternotomy is described
in Chapter 14.
168
(a) Fig. 20.6(a) Cranial In severe bleeding, which is not compressible, consider
extension of the midline
to either side of the
temporary aortic compression below the diaphragm.
xiphoid can provide Clamping of the infradiaphragmatic aorta can be facilitated
several more centimeters by dividing the left crux of the diaphragm at 2 o’clock. At
of exposure.
Xiphoid process this site there are no vessels. However, if there is a
supramesocolic hematoma or bleeding, infradiaphragmatic
aortic clamping may not be possible. In these cases a left
thoracotomy with supradiaphragmatic cross-clamping of
the aorta may be needed. Another alternative is placement
of an endovascular aortic occlusion balloon, insufflated
above the diaphragm.
The exposure and exploration are facilitated by complete
evisceration of the small bowel. Keep the eviscerated bowel
covered with warm and moist towels.
All hematomas due to penetrating trauma should be
explored! The only exception is a stable retrohepatic
hematoma, because it is a difficult and potentially
dangerous maneuver.
Stable hematomas due to blunt trauma should not be
explored. However, exploration should be considered for
all paraduodenal hematomas and for large, expanding, or
(b) leaking hematomas.
After bleeding control, the abdominal cavity should be
explored systematically to identify and treat other injuries.
The intestine should be examined from the ligament of
Treitz to the rectum. Grasp the transverse colon with
two hands and retract towards the patient’s chest. The
ligament of Treitz is at the center and base of the
transverse mesocolon. Ensure that both sides of the
small bowel and mesenteric border are carefully
examined so as to not miss an injury. This is
HEAD
Transv
erse co
lon
Fig. 20.6(b). Extension of the midline laparotomy into a median sternotomy
in cases with associated intrathoracic injuries or severe liver injuries requiring
atriocaval shunt or total liver vascular isolation.
Transverse
Abdominal exploration mesocolon
Upon entering the abdomen, the top priority is the
temporary control of all significant bleeding. This can be
achieved by a combination of packing and direct Treitz ligament
compression.
Blind four-quadrant packing is not as effective as directed
packing! There is no point in packing all quadrants in a Fig. 20.7. Identification of the beginning of the small bowel at the Treitz
ligament. Grasp the transverse colon with two hands and retract towards the
patient with an isolated stab wound to the left upper patient’s chest. The Treitz ligament is at the middle and base of the transverse
quadrant. mesocolon.
169
Section 6: Abdomen
particularly germane to penetrating injuries, especially colon wall should be explored to exclude an
shotgun wounds. underlying injury.
Evisceration of the small bowel to the left or The anterior wall of the stomach and the proximal
right allows careful evaluation of the right and left duodenum can be exposed and inspected by retracting
colon. Hematomas in the fat surrounding the the transverse colon toward the patient’s pelvis.
(a) (b)
HEAD
HEAD
Right colon
Left colon
Fig. 20.8(a),(b). Evisceration of the small bowel to the left allows good exposure and visualization of the right colon (a). Evisceration to the right allows exposure of
the left colon (b). Note the small bowel retracted under the dark blue towel.
Fig. 20.9. Opening of the lesser sac. The stomach

is retracted anteriorly and toward the head and the
transverse colon towards the pelvis. The tense
gastrocolic ligament is opened at its thinnest part
and the sac is entered.
HEAD
Stomach
Transverse
colon
Opening
gastrocolic
ligament
170
The posterior wall of the stomach and the pancreas can closure is acceptable. In all patients, close postoperative
be inspected by dividing the gastrocolic ligament and monitoring of intra-abdominal pressures is warranted
entering the lesser sac. (see Chapter 21).
The liver and spleen should be palpated and visually The skin should be left open in cases where there was intra-
inspected for injuries. The inspection may be operative contamination.
improved by placing laparotomy pads behind the
liver or spleen.
All hollow viscus subserosal hematomas should be
unroofed and examined for underlying perforations.
The diaphragm should always be palpated and Tips and pitfalls
inspected for injuries. Ongoing communication with the anesthesia team is
Both kidneys should be palpated for their presence and critical during the operation.
normal size. This step is important if a nephrectomy is In penetrating abdominal injuries with hemodynamic
considered. If the patient can tolerate it, preserve kidney instability, avoid venous access in the lower extremities,
mass whenever possible. because of the possibility of iliac vein or inferior vena
cava injuries.
The surgeon should consider using a head light,
Intestinal anastomosis especially for injuries located in difficult anatomical
areas.
In trauma, the outcomes are similar for hand-sewn versus
stapled anastomoses or one-layer versus two-layer Open the linea alba 2–3 cm above the umbilicus, where the
anastomosis, and continuous versus interrupted sutures. In aponeurosis is widest to reduce the risk of entering the
pediatric cases a one-layer anastomosis is recommended to rectus sheath.
avoid anastomotic stenosis. All hematomas due to penetrating trauma, irrespective of
size, should be explored. The only exception is a stable
retrohepatic hematoma.
Abdominal closure In multiple small bowel perforations, identify all
perforations before starting repairs. Resecting one segment
Closed drains are recommended in selected cases, such as with a single anastomosis may be safer than multiple
complex liver or pancreatic injuries. There is no role for intestinal repairs in close proximity.
routine drainage. In complex abdominal trauma where the abdominal wall is
Fascial closure should be attempted whenever possible. closed at the index operation, monitor bladder pressures
However, for patients at risk of abdominal compartment postoperatively for the development of intra-abdominal
syndrome or intra-abdominal hypertension, temporary hypertension.
171
Section 6 Abdomen
Damage control surgery

Chapter
21 Mark Kaplan and Demetrios Demetriades
General principles of damage Damage control in vascular trauma

control surgery The standard technical principles used in elective vascular
Damage control (DC) surgery initially referred to surgical surgery may not be applicable in trauma, because of the
techniques used in the operating room. This concept has poor physiological condition of the injured patient.
now been expanded to include damage control The surgeon has many damage control technical options,
resuscitation, which includes permissive hypotension, early including temporary intraluminal shunting, ligation,
empiric blood component therapy, and the prevention and balloon catheter occlusion, and extremity amputation.
treatment of hypothermia and acidosis. Complex repairs, such as end-to-end anastomosis or graft
DC techniques can be applied to most anatomical areas and interposition can be undertaken at a later stage, after
structures, including the neck, chest, abdomen, vessels, and resuscitation and correction of coagulopathy, hypothermia,
fractures. and acidosis.
DC surgery is an abbreviated procedure with the goal Details of vascular damage control techniques are
of rapidly controlling bleeding and contamination so described in other chapters.
that the initial procedure can be terminated, decreasing
surgical stress and allowing a focus on resuscitation. This
should be considered in patients with progressive
Damage control in the chest
physiologic exhaustion who are at risk of irreversible shock Non-anatomical lung-sparing resections, hilar clamping,
and death. After physiologic resuscitation, the patient is hilar twisting, gauze packing of the posterior mediastinum,
returned to the operating room for definitive and temporary chest wall closure are all part of damage
reconstruction and eventual definitive closure of the control in thoracic trauma.
involved cavity. Temporary sternotomy or thoracotomy incision closure
may be necessary in selected cases requiring packing for
The standard indications for DC include:
persistent bleeding or in patients at high risk for
Patients “in extremis,” with coagulopathy, hypothermia postoperative cardiac arrest during the ICU phase of
< 35 °C, acidosis (base deficit >15 mmol/L) resuscitation. In these cases immediate access to the heart
Bleeding from difficult to control injuries (complex for cardiac massage may be life-saving.
liver injuries, retroperitoneum, mediastinum, neck, and Details of damage control operative techniques in the lung
complex vascular) are described in Chapter 17.
In suboptimal environments, such as the rural or
battlefield setting or with inexperienced surgeons
without the adequate skillset to definitively manage the Damage control in the extremities
injury. DC techniques include external fixation, vascular shunting,
For maximum benefit, damage control should be or gauze packing.
considered early, before the patient reaches the in extremis
condition! Take into account the nature of the injury, the
physiologic condition of the patient, comorbid conditions, Damage control in the abdomen
the available resources, and the experience of the surgeon. In abdominal damage control, the goal of the initial
The timing of damage control is critical in determining the exploration is temporary control of bleeding and spillage
outcome. from the intestine. The definitive reconstruction is
172
Chapter 21. Damage control surgery
performed semi-electively, at a later stage, after venous injuries, temporary shunting of injured arteries, or
physiological stabilization. any combination of the above (see Chapter 24).
Temporary closure can be obtained by use of a vacuum- The technique of liver gauze packing (also see Chapter 24),
assisted closure system. following ligation of major sites of bleeding and non-
anatomical resection of non-viable liver, for damage
Temporary control of abdominal control with tight packing tamponade should be
considered if there is persistent bleeding. The liver is
bleeding wrapped with absorbable mesh and gauze packing is
Temporary bleeding control can be achieved by tight gauze applied around it. The mesh stays permanently in the
packing of the source of the bleeding (liver, abdomen and facilitates the removal of the gauze at the
retroperitoneum, and pelvis), application of local second-look laparotomy, without causing bleeding.
hemostatic agents, balloon tamponade in some cases (i.e., Local hemostatic agents are usually effective in
bleeding from a deep penetrating tract in the liver or the controlling minor bleeding, but they rarely work in
retroperitoneum), ligation instead of repair of major major hemorrhage.
(a) (b)
(c) (d)
Fig. 21.1(a)–(d). Severe liver injury requiring damage control with packing (a). After ligation of major bleeders and non-anatomical debridement, the liver is tightly
wrapped with absorbable mesh (b). Tight gauze packing is applied over the mesh (c). Temporary abdominal wall closure with ABThera negative pressure system.
173
Section 6: Abdomen
Control of intestinal spillage (a)
Ligation or stapling of the injured bowel, without

reanastomosis, has been recommended for temporary
control of intestinal content spillage. Definitive
reconstruction is performed at a later stage, usually about
24–36 hours after the initial operation. Some surgeons do
not support this approach because of the concern for
creating a closed loop intestinal obstruction, which may
promote bacterial and toxin translocation and aggravate
bowel ischemia, especially in patients requiring
vasopressors. These authors support reconstruction of the
bowel or ostomy diversion during the damage control
operation whenever possible.
Temporary abdominal wall closure

Following damage control procedures, the abdominal
fascia or skin should never be closed because of the high
risk of intra-abdominal hypertension (IAH) or abdominal (b)
compartment syndrome (ACS). Temporary abdominal
closure (TAC) should always be performed.
The technique used for temporary abdominal wall closure
can influence outcomes, including survival, complications,
and success rate as well as time to definitive fascia closure.
The ideal method of temporary abdominal closure should
prevent evisceration, actively remove any infected or toxin-
loaded fluid from the peritoneal cavity, minimize the
formation of enteroatmospheric fistulas, preserve the facial
integrity, minimize abdominal wall retraction, facilitate
reoperation, and help achieve early definitive closure.
Numerous materials and techniques have been used for
temporary closure over the last decade. They include the
“Bogota bag,” the Wittmann patch, absorbable synthetic
meshes, and various negative pressure therapy (NPT)
techniques. The NPT techniques have the advantage of
active removal of contaminated or toxin-rich Fig. 21.2(a),(b). Temporary abdominal closure with plastic sheet (Bogota
bag). This approach does not allow the effective removal of peritoneal fluid and
peritoneal fluid. does not preserve the abdominal domain.
1. The “Bogota Bag” can easily be constructed with a 3-liter
sterile irrigation bag or a sterile X-ray cassette cover,
stapled or sutured to the fascia or to the skin. It the vacuum-assisted closure (VAC, KCI, San Antonio,
prevents evisceration of the abdominal contents while Texas), and the ABThera (KCI, San Antonio, Texas).
preventing or treating IAH or ACS. It might have limited (a) Barker’s vacuum pack technique consists of a
use in cases with damage control for intra-abdominal fenestrated, non-adherent polyethylene sheet, which is
bleeding, where definitive abdominal closure is placed over the bowel and under the peritoneum,
anticipated within the next 24–48 hours. Its major covered by moist surgical towels or gauze, two large
disadvantage is that it does not allow the effective removal silicone drains placed over the towels, and a transparent
of any contaminated or toxin and cytokine-rich adhesive drape over the wound to maintain a closed
intraperitoneal fluid, and it does not prevent the loss of seal. The drains are connected to continuous wall
abdominal wall domain. suction at 100–150 mmHg. The dressing system is
2. Negative-pressure therapy (NPT) techniques have changed every 24–48 hours and every time the fascia at
revolutionized the management of the open abdomen and the top and bottom of the wound is approximated, if it
have improved survival, morbidity and the success rate of can be done without tension. Some surgeons use this
primary fascia closure. The three most commonly used technique for the first 24–48 hours postoperatively,
NPT techniques are the Barker’s vacuum pack technique, switching to the VAC therapy afterwards.
174
(a) (b)
(c)
Fig. 21.3(a)–(c). Barker’s vacuum pack technique: fenestrated, non-adherent polyethylene sheet is placed over the bowel and under the peritoneum (a), and
covered by moist surgical towels or gauze. Two silicone drains are placed over the gauze (b), and a transparent adhesive drape is placed over the wound to maintain
a closed seal. The drains are connected to continuous wall suction.
(b) The V.A.C.® Abdominal Dressing System (KCI) is a placed directly over the bowel and tucked under the
negative pressure dressing system, which includes peritoneum, into the paracolic gutters and pelvis. The
polyurethane foam, covered with a protective, VPL does not need to be cut; however, if it is, the foam
fenestrated, non-adherent layer, tubing, a collection squares should be divided in the middle, with the
canister, and a computerized pump. The system pulls residual foam pulled out and discarded. Lateral slits
the fascia edges together and prevents adhesions should be made at the level of any ostomies or feeding
between the bowel and anterior abdominal wall, tubes to allow the VPL to fully extend around them. The
making subsequent re-exploration of the abdomen and second layer consists of fenestrated foam cut into the
fascia closure easier and safer. In addition, it actively correct size and shape and placed over the protective
removes any contaminated or inflammatory fluid from foam, under the peritoneum. The third layer consists of
the peritoneal cavity. a similar foam placed over the previous layer, between
(c) The ABThera (KCI) is a new NPT device. It consists of a the fascia edges. The dressing is then covered with a
visceral protective layer (VPL), made of a polyurethane semi-occlusive adhesive drape. A small piece of the
foam with six radiating foam extensions enveloped in a adhesive drape and underlying sponge are excised and
polyethylene sheet with small fenestrations. This layer is an interface pad with a tubing system is applied over this
175
Section 6: Abdomen
(a) (b)
(c)
Fig. 21.4(a)–(c). The V.A.C.® Abdominal Dressing System (KCI). A polyurethane foam, covered with a protective, fenestrated, non-adherent layer (a), is placed over
the intestine, under the peritoneum (b). A perforated polyurethane foam is placed over the first covered foam, covered with transparent adhesive drapes and
connected to a computerized pump (c).
defect and connected to a negative pressure therapy

unit. The negative pressure collapses the foam. A pump
Caution with NPT
canister collects and quantifies the fluid evacuated from In cases with incomplete hemostasis, application of high
the abdomen. Dressing changes are usually done every negative pressure may aggravate bleeding. In these cases an
2 to 3 days. initial low negative pressure is advisable. If large amounts
® of blood are seen in the canister of the vacuum pump, the
The three main NPT modalities (Barker’s, V.A.C.
Abdominal Dressing System, ABThera) have different negative pressure should be immediately discontinued and
mechanical properties, which may affect outcomes. the patient returned to the operating room for re-
The most important difference is the distribution exploration and bleeding control.
pattern of the preset negative pressures, with ABThera IAH may occur in rare cases with temporary abdominal
having a more even distribution and sustained NPT, wall closure with NPT dressing. The bladder pressure
promoting a more effective removal of any should be monitored routinely during the first few hours of
intraperitoneal fluid. negative-pressure dressing application.
176
Fig. 21.5. ABThera negative pressure system for

temporary abdominal closure: (A) visceral
protective layer, (B) fenestrated foam, (C) semi-
E occlusive adhesive drape, (D) tubing with interface
pad, (E) pump.
C
B
(a) (b)
Fig. 21.6(a)–(d). Application of ABThera (KCI) for temporary abdominal closure. (a) Severe liver injury with perihepatic packing (arrow). (b) Application of the
visceral protective layer over the intestine and under the peritoneum. (c) Application of two layers of fenestrated foam (one under the peritoneum and one between
the edges of the abdominal wound), covered with transparent occlusive adhesive drape. (d) Interface pad and suction tubing.
177
Section 6: Abdomen
(c) (d)
Fig. 21.6(a)–(d). (cont.)
(a) (b)
2 2 2
2 2 12
12 12
8 8 8
8 8 12 19
9 9 19 19 12
2 8 9 9 9 8 2 19 43 43 19
9 9
12 12
19 43 43 43 19
8 8
8 8 8 43 43
19 19
2 2
12 19 19 12
19
2 2 2
12 12
12
Fig. 21.7. Distribution of negative pressure of 125 mmHg with the Barker’s (a), V.A.C.® abdominal dressing system (b), and ABThera system (c). The distribution of
negative pressures affects the efficacy of removal of any intraperitoneal fluid (d).
178
(c) (d)
1.000
15 0.900
71 71 0.800 ABThera
15 73 26 73 15
0.700
26 26
Volume (liters)
88 88 0.600 VAC
71 73 88 88 88 73 71
0.500
88 88
26 26 0.400 BARKER’s
15 73 26 73 15 0.300
71 71 0.200
15
0.100
0.000
0.00 5.00 10.00 15.00 20.00 25.00 30.00
Time (minutes)
Fig. 21.7. (cont.)
Comparison of NPT techniques for temporary In patients with persistent large fascial defects, definitive
reconstruction should be considered, using synthetic or
abdominal closure biological meshes or sheets, or autologous tissue transfer
There is evidence that the ABThera™ Negative Pressure with component separation.
Therapy System (KCI USA, Inc., San Antonio, TX, USA),
is associated with a significantly higher 30-day primary
fascia closure rate and a lower mortality rate than the Tips and pitfalls
Barker’s technique. The superior outcomes with ABThera Consider early damage control, before the patient becomes
have been attributed to the more effective removal of toxic in extremis. The timing of damage control is critical in
lymph and cytokine and toxin-loaded peritoneal fluid. determining the outcome.
Interventional radiology is an important component of
damage control. Consider going to the angiography suite
Definitive fascia closure straight from the operating room or utilize a hybrid
Early, definitive closure of the abdomen reduces the operating room if available.
complications associated with the open abdomen. The Postoperative continuous bleeding after damage
closure should be achieved without tension or risk of control must be examined in the operating room
recurrence of IAH. immediately. Do not assume that it is coagulopathic
Primary fascia closure may be possible in many cases within bleeding!
a few days of the initial operation, and should be considered The type of negative pressure therapy used for temporary
when all intra-abdominal packing has been removed, any abdominal closure can influence outcomes.
residual infection is cleared, and the bowel edema subsides. In the presence of bleeding avoid using high negative
In some patients early definitive fascial closure may not be pressure therapy.
possible because of persistent bowel edema or intra- In applying ABThera or any other NPT, make sure
abdominal sepsis. In these cases, progressive closure should that the foam does not come into direct contact
be attempted at every return to the operating room for with the bowel because of the risk of fistula
dressing change, by placing a few interrupted sutures at the formation.
top and bottom of the fascia defect.
179
Section 6 Abdomen
Gastrointestinal tract
Chapter
22 Kenji Inaba and Lisa L. Schlitzkus
Special surgical instruments Subcostal extensions may be required for cases with
complex hepatic or gastroesophageal (GE) junction injuries.
General laparotomy tray
In a hypotensive patient, the abdomen should be entered
Bookwalter or other fixed abdominal retractor
using the scalpel in three strokes. First, the skin is incised,
Both TA and GIA stapling devices followed by the subcuticular tissue, and then the linea alba.
Ostomy supplies A finger can be used to enter the peritoneal cavity just
An electrothermal bipolar vessel sealing system device superior to the umbilicus at the thinnest point. Mayo scissors
(LigaSure device) can then be used to extend the peritoneal incision. Cautery
Adequate lighting including a headlight. electrodissection may be used in hemodynamically stable
patients under direct visualization.
Positioning
The patient should be placed in the supine position with Stomach
the arms abducted to 90 degrees.
The bed rails should be free and exposed for retractor placement.
Surgical anatomy
The lesser curvature is supplied by the left and right gastric
Standard trauma preparation of skin from chin to knees
arteries. The origin of the right gastric artery is highly
and laterally to the bed.
variable, but generally originates from the proper hepatic
If based on pre-operative imaging, there is a possibility of artery. The left gastric artery arises from the celiac trunk
multiple compartment operations including a laparotomy
and is encased in the hepatogastric ligament. It gives off the
and thoracotomy with one hemithorax involved, the patient
esophageal artery before following the lesser curvature to
can be positioned in a modified taxi-cab hailing position. The
anastomose with the right gastric artery.
patient is placed supine with the injured hemithorax medially
The greater curvature is supplied by the left and right
rotated 30° anterior to the coronal plane, facilitating further
gastroepiploic arteries. The right gastroepiploic artery is an
exposure of the chest wall. A beanbag, folded blankets, or a
end branch of the gastroduodenal artery. The left
roll may be used to elevate and support the chest. Abduct the
gastroepiploic artery branches off the splenic artery and
arm and slightly flex the elbow. The arm can be prepped into
anastomoses with the right.
the field if manipulation is required. In general, however, to
accommodate any injuries that may be encountered, it is The fundus of the stomach is also supplied by the short
gastric arteries that arise from the distal splenic artery.
preferable to use the utility supine position.
The venous drainage parallels the arteries. The gastric veins
In suspected low rectal injuries, the patient may be placed
drain into the portal veins, while the left gastroepiploic and
in the lithotomy position to facilitate diagnostic
short gastric veins first enter the splenic vein and ultimately
sigmoidoscopy or transanal repair of a rectal injury.
the portal vein. The right gastroepiploic vein drains directly
into the superior mesenteric vein.
Incisions The angular incisure is the indentation approximately two-
A midline laparotomy incision provides the ideal thirds of the way along the lesser curvature, and is a
exposure for all gastrointestinal tract injuries. landmark for the end of the body and the beginning of the
Adequate visualization and access should not be pyloric antrum.
compromised by the length of the incision. Extension The upper part of the stomach begins with a physiologic
from xiphoid to pubic symphysis may be required, sphincter, the lower esophageal sphincter. The outlet
especially in hemodynamically compromised patients. consists of a thickened muscular ring called the pylorus.
180
Chapter 22. Gastrointestinal tract
The spleen is posterolateral to the fundus of the stomach, General principles

and the stomach creates an impression on the medial,
Most gastric injuries are secondary to penetrating trauma
visceral aspect of the spleen. The short gastric arteries lie
and are identified during operative exploration.
within the gastrosplenic ligament.
The stomach is redundant and can be easily managed with
The anterior surface of the body of the pancreas is located
primary suture closure in one or two layers or stapled wedge
posterior and inferior to the stomach.
resection of the injured segment except near the GE junction
The left portion of the transverse colon lies posterior and and pylorus. For these injuries, see description below.
inferior to the stomach. The gastrocolic ligament attaches
The anterior and posterior walls of the stomach must be fully
to the greater curvature of the stomach and to the superior,
visualized to exclude injuries regardless of the mechanism.
anterior surface of the transverse colon.
Division of the gastrocolic ligament allows entrance into
the lesser sac for exposure of the posterior wall of the
(a) Fig. 22.1(a). One surgeon grasps the stomach with one hand and the opposite
transverse colon in the other hand. The second surgeon or assistant enters
the avascular plane of the gastrocolic ligament.
STOMACH
Gastrocolic
ligament
Transverse
colon
(b) Fig. 22.1(b). After division of the gastrocolic ligament, elevating the stomach
with downward traction of the transverse colon provides the critical view of
the posterior wall of the stomach and the pancreas.
Posterior wall
of the
stomach
Pancreas
Transverse colon
181
Section 6: Abdomen
stomach. Elevation of the stomach with downward (c)

retraction of the colon provides the critical view. A wide
malleable retractor withdrawn slowly may facilitate viewing
the posterior wall of the stomach.
Distal esophageal injuries

The gastroesophageal junction may be better visualized by
placing the patient in the reverse Trendelenberg position.
Taking down the triangular ligament and retracting the left
lobe of the liver and dividing the gastrohepatic ligament, or
the lesser omentum, exposes the medial aspect of the GE
junction. To gain access to the lateral aspect, the short gastric
Esophagus
(a)
Falciform
ligament
Left triangular
Fig. 22.2(c). Vessel loop around the esophagus and enter downward, caudal
ligament
retraction on the stomach, exposes the esophagus and gastroesophageal
junction.
(d)
Left lobe, liver
Stomach
Fig. 22.2(a). Exposure of the gastroesophageal junction can be achieved by

adequate mobilization and medial retraction of the left lobe of the liver and
division of the gastrohepatic ligament. The falciform and and left triangular
ligament are divided; division of the left triangular ligament of the liver
(interrupted line).
Left crura Left

(b)
diaphragm
Left diaphragm
Fig. 22.2(d). Division of the diaphragmatic crura maximizes the exposure of

the distal esophagus.
abrir crura en hora 2 porque a ese nivel no hay vasos

Liver
Spleen arteries can be divided. A Penrose can be placed around the

GE junction to retract it caudally. Use of a Bookwalter or
other fixed abdominal retractor and a headlamp can
Esophagus improve the exposure. Division of the diaphragmatic crura
provides the maximal exposure cranially.
STOMACH
Most simple injuries can be primarily repaired with
absorbable 3–0 interrupted sutures in one layer. The repair
may be buttressed with omentum, pleura, muscle, or stomach.
Fig. 22.2(b). Medial rotation of the liver, division of the gastrohepatic
ligament and division of the short gastric arteries along the greater curvature Larger injuries may require resection and re-anastomosis,
exposes the gastroesophageal junction. which can be handsewn or stapled utilizing an EEA stapler.
182
(a) (b)
Liver
Left diaphragm
Esophagus Stomach
Fig. 22.3(a). Stapled esophago-gastrostomy: the EEA anvil can be placed through Fig. 22.3(b). A separate gastrotomy can be made to insert the EEA stapler.
the injury site and pushed cranially in the esophagus. The injured GE junction can
then be resected, and the anvil brought out the distal healthy end of the esophagus.
(c) (d)
Left
Liver
diaphragm
Stomach
Fig. 22.3(c). The circular stapler creates a neo-gastroesophageal junction (arrows). Fig. 22.3(d). The gastrotomy can later be closed with a TA or GIA stapler.
All devitalized tissue should be debrided. An anterior Tips and pitfalls

gastrotomy allows insertion of the EEA stapler and this
Exposure and good lighting are critical for avoiding missed
opening can be closed using a GIA or TA stapler.
injuries. All hematomas along the curvatures must be
opened and explored for underlying perforations. Injuries
to the posterior wall and along the curvatures of the
Pyloric injuries stomach may be easily missed, even in the absence of an
This area is prone to stenosis. Simple injuries may be anterior injury.
repaired with a pyloroplasty, but destructive injuries may Excessive tension on the stomach may easily tear the short
require an antrectomy. gastric vessels and cause iatrogenic bleeding.
Options for reconstruction include a Billroth I, Billroth II,
or a Roux-en-Y reconstruction. Small intestine
The gastrojejunostomy may be stapled or handsewn,
antecolic or retrocolic. If the jejunum is brought through Surgical anatomy
the mesocolon, the middle colic vessels should be avoided The jejunum begins at the ligament of Treitz and the ileum
and the jejunum secured to the mesocolon to prevent an terminates at the ileocecal valve. About two-fifths of the
internal hernia. small intestine is jejunum and the remainder is ileum.
183
Section 6: Abdomen
The mesentery is the folding of peritoneum over the (b)

vascular supply and attaches the small intestine to the
posterior abdominal wall. The attachment is about
15 centimeters from the upper left to lower right of the
abdomen.
The jejunum and ileum are supplied by the superior
mesenteric artery (SMA) and drainage is by the superior
mesenteric vein (SMV). The artery has multiple arcades,
and the veins parallel the arteries. The SMV lies slightly
anterior and to the right of the SMA within the mesentery
and joins the splenic vein to form the portal vein posterior
to the neck of the pancreas.
General principles
Injury should be suspected in any penetrating trauma that
enters or traverses the peritoneal cavity. Multiple
concurrent injuries may be present along the length of the
small bowel.
Perforation after blunt trauma results from shearing forces
or bowel entrapment causing a closed loop obstruction
with perforation due to a sudden increase in intraluminal Fig. 22.4(b). Bucket handle injury of the small bowel mesentery due to
pressure. Traction injuries may occur at points of fixation deceleration injury. Note the ischemic necrosis of the bowel.
such as the ligament of Treitz or the ileocecal junction.
A bucket handle injury of the mesentery may also occur
where the bowel is initially intact and viable, but later
necroses due to impaired blood supply from an injured The small intestine must be examined from the ligament of
mesentery. Treitz to the ileocecal valve. The entire circumference of
the intestine including the mesenteric border should be
(a) visualized. Stay methodical to avoid missing injuries.
Transverse
mesocolon
Fig. 22.4(a). Small bowel perforation in blunt abdominal trauma due to

increased intraluminal pressure. The perforation usually occurs at the
antimesenteric border. Fig. 22.5. The ligament of Treitz (arrow) is at the base and middle of the
transverse mesocolon.
184
Resection versus repair In planning major small bowel resections, try to preserve a
minimum of 100 cm of small bowel to avoid “short bowel
If multiple injuries are identified, consider a single rather
syndrome.”
than multiple anastomoses.
Consider hand-sewn rather than stapled anastomosis in the
All injuries should be closed in a transverse orientation to
presence of bowel edema.
avoid narrowing the lumen.
Bowel left in discontinuity following damage control may
Resection versus primary repair will depend on the extent
be at risk of ischemia; when able, perform the anastomosis
of the injury.
at the index operation.
Intestinal anastomosis
The outcomes are similar for hand-sewn versus stapled Colon
anastomoses for trauma.
In settings where the bowel is edematous, friable, or where Surgical anatomy
there is a large size mismatch, a hand-sewn anastomosis The colon is divided into four parts: the ascending,
may be preferred. transverse, descending, and sigmoid. Along the length of the
Even in the damage control setting, always attempt to colon are three longitudinal muscles called the taenia coli.
perform the gastrointestinal tract anastomosis at the first The cecum is the first part of the ascending colon. It has no
operation. If unable, stapling and leaving the patient in mesentery, is almost entirely covered by peritoneum, and
discontinuity may be considered. gives off the appendix. Its vascular supply is the ileocolic
artery and vein, an end branch of the SMA and SMV. The
appendiceal artery, a branch of the ileocolic, lies within the
mesentery of the appendix.
The remainder of the ascending colon is retroperitoneal
and can be freed by taking down the white line of Toldt. It
is supplied by the right colic artery, a branch of the SMA,
and drains by the right colic vein into the SMV. The
ascending colon transitions into the transverse colon at the
hepatic flexure located at the inferior edge of the liver.
The transverse colon is the largest and most mobile part of
the colon. It is supplied by the middle colic artery from the
SMA with the parallel veins draining into the SMV. The
transverse colon ends at the splenic flexure. This turn is
more acute, less mobile and more superior than the hepatic
flexure. This is also the watershed transition point of the
vascular supply from the superior mesenteric vessels to the
inferior mesenteric vessels.
The descending colon mirrors the ascending, but on the
left. It is supplied by the left colic artery and vein, which
originate from the inferior mesenteric artery (IMA) and
Fig. 22.6. Distended and ischemic segment of bowel proximal to the staple inferior mesenteric vein (IMV). As the descending colon
line in a patient who had a damage control procedure with bowel stapled and becomes more mobile and turns midline to drop down into
left in discontinuity. the pelvis, it becomes the sigmoid colon supplied by the
sigmoid artery. The sigmoid and left colic vein drain into
Tips and pitfalls the IMV, then the splenic vein to enter the portal vein.
All bowel wall hematomas due to penetrating trauma must
be unroofed and explored. A common error is the failure to
explore hematomas at the junction of the bowel and the General principles
mesentery. Hemorrhage must first be controlled, followed by
Perform a complete evaluation of the small bowel before contamination control. Once all injuries are identified,
starting any repairs or resections. The presence of other definitive repair can be undertaken. Contamination control
perforations may change the management plan. may include placing a Babcock on the injury, oversewing,
In cases with multiple small bowel perforations, a single or stapling the injury.
resection of a larger segment is preferable to multiple Antibiotics to include aerobic and anaerobic coverage
smaller resections. should be given preoperatively to all suspected colon
185
Section 6: Abdomen
injuries and should not be continued for more than (a)

24 hours postoperatively unless active infection is present.
Primary repair is advocated in all non-destructive colon
injuries. The majority of destructive injuries requiring
resection can safely be managed with primary anastomosis.
Diversion should be considered in cases with massive wall
edema, poor quality colon tissue, or questionable blood supply.
The risk of intra-abdominal infection following destructive Stomach Spleen
colon injuries requiring resection is high, irrespective of
the method of management.
Hand-sewn anastomoses are favored for edematous bowel, Splenocolic
otherwise a stapled anastomosis can be used. ligament
Given the complications of bowel left in discontinuity during

damage control, an attempt at primary anastomosis should Splenic flexure,
be performed whenever possible at the index operation. colon
Mobilization is key to evaluating the colon. The right and
left colon may be taken down along the white line of Toldt.
The splenocolic and hepatocolic ligaments may be divided.
During mobilization of the splenic flexure, excessive
traction on the colon may cause avulsion of the splenic
capsule with bleeding. Fig. 22.8(a). During mobilization of the splenic flexure of the colon and
During mobilization of the right or left colon, the ureters division of the splenocolic ligament, avoid excessive traction on the colon to
prevent avulsion of the splenic capsule.
should be identified and protected.
(b)
HEAD
Splenocolic
ligament
Duodenum
Left colon
right
Fig. 22.7. Mobilization and medial rotation of the right colon exposes the Fig. 22.8(b). Excessive traction on the splenic flexure of the colon may cause
C loop of the duodenum. avulsion of the splenic capsule and bleeding.
186
Resection versus repair Rectum

For penetrating colon injuries, primary repair is Surgical anatomy
recommended. For simple wounds, debridement followed
by a one- or two-layer repair is acceptable using a The rectum is approximately 15 centimeters long and is
transmural absorbable running or interrupted inner layer. only partially intraperitoneal. The anterior and lateral sides
If used, the second layer would consist of interrupted of the upper third and the anterior middle third are
Lembert sutures. covered by peritoneum. The lower third of the rectum is
completely extraperitoneal.
Resection is required when the injury encompasses >50
percent of the circumference or when it results in a The rectum is highly vascular. The superior rectal artery
devascularized segment. The anastomosis may be from the IMA supplies the upper third, the two middle
hand-sewn or stapled. rectal arteries from the internal iliac arteries supply the
middle third and the inferior rectal arteries from the
A common injury pattern is de-serosalization, usually
internal pudendal arteries supply the lower third, the
of the sigmoid colon. Separation of the muscular and
anorectal junction, and the anal canal. The superior rectal
serosal layers occurs with an intact mucosal tube.
veins drain into the IMV (portal system), whereas the
To repair, telescope the mucosa back upon itself.
middle and inferior rectal veins drain into the internal iliac
Debride the muscular and serosal edges, and then
and internal pudendal veins (systemic).
reapproximate them with one layer of interrupted or
running suture. The mucosa within will redistribute and
does not lead to stenosis or obstruction. Healing occurs General principles
without having to open the lumen, avoiding Injuries to the intraperitoneal rectum are treated like
contamination. Extensive defects, especially those with colonic injuries.
associated mesenteric injury, will require resection and Extraperitoneal rectal injuries are rare after blunt trauma
anastomosis. due to the protection afforded by the bony pelvis. They can,
however, result from bone fragments secondary to pelvic
fracture or from rectal foreign bodies. The majority of
extraperitoneal injuries result from transpelvic gunshot
Wound closure wounds. This should be suspected if blood is noted on
The skin should always be left open because of the digital rectal examination or if there is a suspicious missile
high incidence of wound infection and fascial trajectory seen on CT.
dehiscence with primary skin closure. Delayed primary For these patients, the diagnosis can be confirmed by
closure can be performed 3–4 days after the initial anoscopy followed by sigmoidoscopy. If an associated
operation. intraperitoneal component of the rectal injury is suspected,
laparoscopic confirmation or laparotomy can be
performed. Isolated small, non-destructive extraperitoneal
Tips and pitfalls injuries can be observed or repaired through a trans-anal
approach. Routine diversion is not necessary.
All paracolic hematomas due to penetrating trauma should
A large destructive extraperitoneal rectal injury may be
be explored.
primarily repaired and protected using a diverting ostomy.
Excessive tension on the hepatic and splenic flexures may
Some large injuries cannot be repaired due to their
cause capsular tears and further bleeding.
anatomical location. Diversion alone has been used with
Whenever possible, the colon should be transected success.
obliquely, with the mesenteric border left longer than the
A properly constructed loop colostomy may achieve
anti-mesenteric border in order to optimize blood supply
complete fecal diversion, thus avoiding the complex
to the bowel wall.
reconstruction required after a Hartmann end-colostomy.
Adequate debridement of all penetrating wounds, The Hartmann’s procedure should be reserved for patients
especially gunshot wounds, is critical before a repair is with extensive destruction of the rectum.
performed. In destructive injuries the bowel wall should be
Routine pre-sacral drainage and distal rectal washout for
resected to well-perfused and healthy edges.
extraperitoneal rectal injuries are no longer recommended.
While the colon is unlikely to become narrowed, all injuries
should be closed in a transverse orientation to avoid this
complication. Tips and pitfalls
Injuries to the splenic flexure can be difficult to expose and Patients with suspected extra-peritoneal rectal injuries
the flexure should be taken down to allow adequate should be placed on the operating table in the lithotomy
visualization. position for anoscopy and sigmoidoscopic evaluation with
187
Section 6: Abdomen
(a) (b)
Proximal loop
Distal loop
Distal loop
Fig. 22.9(a). Loop colostomy with complete fecal diversion. A “bridge” is

created with a plastic rod placed through the mesocolon close to the distal
loop of the colostomy.
Fig. 22.9(b). Loop colostomy with complete fecal diversion, using a heavy
horizontal mattress suture as a temporary bridge (thick arrows), close to the
distal loop of the colostomy, through the aponeurosis of the external oblique
muscle.
(c) Fig. 22.9(c) Completion of the diverting loop

colostomy. Loop colostomy with complete fecal
diversion. A “bridge” is created by a plastic rod
placed through the mesocolon close to the distal
loop of the colostomy (left). Alternatively, a heavy
horizontal mattress suture (silk 1) through the
aponeurosis of the external oblique muscle and
the mesocolon can be used instead of the plastic
rod (right).
Distal loop Proximal loop
possible trans-anal repair. In the hemodynamically Associated bladder or iliac vascular injuries are common.
unstable patient due to associated intra-abdominal injuries, Every effort should be made to separate the repairs with
an exploratory laparotomy for bleeding control precedes well-vascularized tissue such as omentum, in order to
the rectal evaluation. reduce the risk of vascular graft infection or the formation
A properly constructed loop colostomy can provide of a rectovesical fistula.
effective fecal diversion and be the primary treatment for Complex anorectal injuries after open pelvic fractures
an extraperitoneal rectal injury. Alternatively, a heavy should be managed acutely with hemostasis, wound
horizontal mattress suture (silk 1) through the aponeurosis packing, and a sigmoid colostomy.
of the external oblique muscle and the mesocolon can
achieve an excellent fecal diversion.
188
Section 6 Abdomen
Duodenum
Chapter
23 Edward Kwon and Demetrios Demetriades
Surgical anatomy gastroduodenal artery, common bile duct, and the

portal vein.
The duodenum lies in front of the right kidney and renal
The descending or second portion is bordered
vessels, the right psoas muscle, the inferior vena cava, and
posteriorly by the medial surface of the right kidney,
the aorta.
the right renal vessels, and the inferior vena cava. The
transverse colon crosses anteriorly. The common bile
duct and main pancreatic duct drain into the medial
wall of the descending duodenum.
The transverse or third portion is also entirely
retroperitoneal. Posteriorly, it is bordered by the inferior
vena cava and the aorta. The superior mesenteric vessels
cross in front of this portion of the duodenum.
The ascending or fourth portion of the duodenum is
approximately 2.5 cm in length and primarily
retroperitoneal, except for the most distal segment.
Posteriorly, it is bordered by the aorta and it ascends to
the left of the aorta to join the jejunum at the ligament
of Treitz.
The common bile duct descends within the
hepatoduodenal ligament to course posterior to the first
portion of the duodenum and pancreatic head, becoming
partially invested within the parenchyma of the pancreas.
The main pancreatic duct then joins the common bile duct
to drain into the ampulla of Vater within the second
portion of the duodenum. The ampulla of Vater is located
Fig. 23.1. The duodenum lies in front of the right kidney and renal vessels,
the inferior vena cava, and the aorta. Exposure after medial rotation of the approximately 7 cm from the pylorus. The accessory
duodenum and head of the pancreas. pancreatic duct drains approximately 2 cm proximal to the
ampulla of Vater.
The vascular supply to the duodenum is intimately
The duodenum is approximately 25 cm in length. It is the associated with the head of the pancreas. The head of the
most fixed part of the small intestine and has no mesentery. pancreas and the second portion of the duodenum derive
It is anatomically divided into four parts: their blood supply from the anterior and posterior
The superior or first portion is intraperitoneal along the pancreaticoduodenal arcades. These arcades lie on the
anterior half of its circumference. Superiorly, the first surface of the pancreas near the duodenal C loop. Attempts
portion is attached to the hepatoduodenal ligament. to separate these two organs at this location usually result
The posterior border is associated with the in ischemia of the duodenum.
189
Section 6: Abdomen
Common Fig. 23.2. The head of the pancreas and the

Gastroduodenal hepatic second portion of the duodenum derive their
artery artery blood supply from the anterior and posterior
pancreaticoduodenal arcades. Attempts to
separate the two organs at this location usually
result in ischemia of the duodenum.
Anterior
pancreaticoduodenal
arcade
Superior mesenteric
artery
General principles
All periduodenal hematomas secondary to blunt or
penetrating trauma found during laparotomy should be
explored to rule out underlying perforation.
Fig. 23.3. Hematoma of the second part of the

duodenum due to blunt trauma. All duodenal
hematomas secondary to blunt or penetrating
trauma found during laparotomy should be
explored to rule out underlying perforation.
First part
Hematoma duodenum
second part duodenum
Head of
pancreas
190
Chapter 23. Duodenum
The majority of duodenal lacerations can be managed with Special surgical instruments
debridement and transverse duodenorrhaphy.
Complete trauma laparotomy tray, Bookwalter
Resection and primary anastomosis of the second portion self-retaining abdominal retractor, surgical headlight,
of the duodenum are tenuous due to the high risk of
and tube for possible jejunal feeding access.
vascular compromise during mobilization and proximity
to the ampulla of Vater.
Injuries involving the medial aspect of the second portion
of the duodenum may be more effectively explored from Positioning
within the lumen via a lateral duodenotomy. Avoid Standard supine positioning with arms abducted to 90
dissection of the duodenum from the head of the pancreas degrees
due to the high risk of devascularization and duodenal Standard trauma preparation from the nipples to the mid
necrosis. thighs.
Routine pyloric exclusion should not be performed.
Exclusion should be reserved for severe injuries requiring a
Incision
complex repair or a repair with tenuous blood supply.
In complex pancreaticoduodenal injuries, consider damage
control techniques and delayed reconstruction. A standard midline laparotomy incision from the xiphoid
Wide local drainage with closed suction drains of duodenal process to the pubic symphysis.
repairs should be performed. The drains should not
directly overlie the repair.
Distal feeding access, through a feeding jejunostomy, Operative technique
should routinely be considered in patients with complex
duodenal injuries. Exposure
Although rare, severe destructive injuries to the duodenum A self-retaining abdominal retractor is useful to retract the
that include the pancreatic head may require a abdominal wall and the liver cephalad to expose the
pancreaticoduodenal resection. These cases should be duodenal–pyloric junction.
handled using damage control principles with a staged The anterior surface of the first portion of the duodenum is
resection followed by delayed reconstruction. readily visible.
Fig. 23.4. Duodenum in situ. The anterior half of

the first portion of the duodenum is intraperitoneal
and easily visible. The hepatoduodenal ligament is
attached to the superior aspect of the first portion
of the duodenum. The proximal aspect of the
second portion of the duodenum is also visible,
Liver although often the second portion is covered
Hepatoduodenal anteriorly by the hepatic flexure of the colon.
ligament
First portion of
duodenum
Second portion of
duodenum
Stomach
Colon
Hepatic flexure
Gastrocolic ligament
191
Section 6: Abdomen
A Kocher maneuver is performed by incising The C-loop of the duodenum and the pancreatic head
the lateral peritoneal attachments of the first, are retracted medially to expose their posterior surfaces.
second, and proximal third portions of the Avoid excessive superior traction to prevent superior
duodenum to the superior mesenteric vein (SMV) mesenteric vein injury.
exposing their lateral aspects. Avoid injury to Gerota’s fascia of the right kidney and the inferior vena
the SMV. cava are visible posteriorly.
Fig. 23.5. Kocher maneuver: the posterior and lateral aspects of the second
portion of the duodenum may be exposed by performing a Kocher maneuver.
The lateral peritoneal attachments of the first, second, and proximal third
portions of the duodenum are incised and the pancreaticoduodenal complex is
retracted medially. Note the exposure of the inferior vena cava and renal veins,
deep to the pancreaticoduodenal complex.
Renal
veins
Inferior vena cava Aorta
(a) Fig. 23.6(a). Kocher maneuver: the hepatic

flexure of the colon is mobilized and retracted
toward the pelvis, revealing the underlying anterior
and lateral surface of the second and proximal third
portion of the duodenum.
First portion of
duodenum
Liver
Second portion of Stomach

duodenum
Third portion of
duodenum
Hepatic flexure of colon

mobilized
192
(b) Fig. 23.6(b). Kocher maneuver: the lateral

attachments of the duodenum are sharply divided,
exposing the lateral and posterior surfaces of the
second portion of the duodenum.
Liver
Hepatoduodenal
ligament
Second portion of
duodenum
retracted medially
(c) Fig. 23.6(c). Kocher maneuver: the duodenum is

mobilized medially until the IVC and left renal vein
are encountered (IVC ¼ inferior vena cava).
Liver
Left renal vein

Head of
pancreas Second portion of
duodenum
retracted medially
IVC
Colon
Hepatic flexure
To increase exposure to the remainder of the third and small bowel mesentery, in an oblique fashion from the
fourth portions of the duodenum and retroperitoneal ileocecal junction towards the ligament of Treitz. The
vessels, a right medial visceral rotation or Cattell–Braasch right colon and small bowel are retracted cephalad and
maneuver is performed. to the left.
Incise the lateral peritoneal attachments of the right The superior mesenteric vessels are retracted
colon from the hepatic flexure to the cecum and retract with the small bowel, towards the patient’s head
the colon medially. and left side, and are no longer crossing the
Continue the inferior margin of the lateral peritoneal duodenum. The third and fourth portions are now
incision onto the visceral peritoneum, posterior to the accessible.
193
Section 6: Abdomen
(a) Fig. 23.7(a). Cattell–Braasch maneuver. After

mobilization of the right colon, the bowel is
retracted to the right. An incision is then made on
HEAD the visceral retroperitoneum, posterior to the small
bowel mesentery (red line), in an oblique fashion
from the ileocecal junction towards the ligament of
Treitz.
Bowel tracted
to the right
Ligament of Treitz
Ileocecal junction
(b)
First portion of duodenum
Liver
Viscera
retracted
superiorly and
to the left
Head of
pancreas
Second portion
of duodenum
Third portion of duodenum Fourth portion of duodenum
Fig. 23.7(b). Complete exposure of all parts of the duodenum after Cattell–Braasch maneuver. The viscera is retracted superiorly and to the left. Note the superior
mesenteric vessels are no longer crossing the duodenum.
194
The distal fourth portion of the duodenum can also be duodenum emerges from the retroperitoneum attached
exposed by incising the ligament of Treitz. to the superior aspect of the duodenum.
The transverse colon is retracted superiorly and the The root of the mesentery should be palpated to
small bowel is gently retracted inferiorly and to the identify the location of the superior mesenteric vessels
right. The ligament of Treitz is identified at the root of to the right of the ligament of Treitz to prevent injury
the mesentery where the fourth portion of the prior to division.
(a) Fig. 23.8(a). The distal most part of the fourth portion of the duodenum is
attached to the ligament of Treitz. The Treitz ligament is at the middle and
base of the transverse mesocolon.
HEAD
Transv
erse c
olon
Transverse
mesocolon
Ligament
of
Treitz
Proximal jejunum
(b) Fig. 23.8(b). Division of the ligament of Treitz to the right of the
duodenojejunal junction. The superior mesenteric artery is to the left of the
junction.
Transverse colon and mesocolon
retracted superiorly
Duodenal–
jejunal junction
Ligament of Treitz
195
Section 6: Abdomen
Alternatively, the hepatic flexure of the colon can be An anterior gastrotomy is created along the greater
mobilized inferiorly by serially ligating and dividing the curvature of the stomach, near the pylorus.
gastrocolic omentum from the mid transverse colon to the The pylorus is identified and grasped via the
hepatic flexure and incising the peritoneal attachments gastrotomy with a Babcock clamp and a purse-string
laterally. An electrothermal bipolar vessel sealing system suture using a size 0 absorbable suture is placed.
(LigaSure device) may be used as a safe and faster An alternative technique involves stapling of the post-
alternative to vessel ligation and division. pyloric duodenum with a TA 55 4.8 mm stapling
The lesser sac is exposed and the anteromedial surfaces of device.
the second portion of the duodenum and head of the A gastrojejunostomy is created utilizing the previous
pancreas are visible. gastrotomy.
Repair (a)
All duodenal hematomas identified intraoperatively must

be explored to rule out underlying perforation.
A seromuscular incision is made overlying the hematoma
PYLORUS
and the hematoma is evacuated. The duodenum should be
carefully examined for full thickness injury at the site of the
hematoma.
STOMACH
Most duodenal lacerations can be debrided and repaired
primarily. Repairs should be performed transversely in two
layers using a full thickness continuous 3–0 absorbable
suture as the inner layer and 3–0 seromuscular Lembert Greater
curvature
sutures as the outer layer.
If adequate mobilization is not possible for transverse
closure, the injury may be repaired in a longitudinal
fashion if there is not significant luminal narrowing. If
there is significant stenosis, a gastrojejunostomy should
Fig. 23.9(a). Pyloric exclusion: a gastrotomy (circle) is created along the
be performed in addition to the repair. greater curvature, which will also be used to create a gastrojejunostomy.
Some injuries may not be able to be repaired primarily
and require more complex repairs such as jejunal
mucosal patch or serosal patch. A serosal patch may
also be utilized to buttress a repair. (b)
Transections and injuries involving >50% of the
circumference of the first, third, and fourth portions of the
duodenum may require segmental resection and
duodenoduodenostomy or duodenojejunostomy.
The injured segment is resected and a two-layer end-to-
end anastomosis is created using a full thickness
continuous 3–0 absorbable suture and seromuscular
3–0 Lembert sutures. STOMACH
If a tension-free anastomosis is unable to be created a
Roux-en-y duodenojejunostomy may be required.
Segmental resection of the second portion is limited by the
ampulla of Vater and by the common blood supply with Pylorus delivered
via gastrotomy
the pancreas, making it particularly susceptible to vascular
compromise during mobilization.
Pyloric exclusion should be used selectively for injuries
involving the second portion of the duodenum, combined
pancreatic and duodenal injuries, and otherwise tenuous Fig. 23.9(b). Pyloric exclusion. The pylorus is grasped with a Babcock clamp
repairs. via the gastrotomy and delivered.
196
(c) These patients are often hemodynamically unstable and

these injuries are best managed with completion of the
resection and delayed reconstruction as a second
planned operation.
LIVER
Associated sources of hemorrhage should be considered
and include from superficial to deep: (1) duodenum
and pancreas, (2) superior mesenteric vessels and
portal vein, (3) inferior vena cava, renal vessels
and aorta.
Damage control techniques for duodenal injuries
include resection without anastomosis or wide
drainage and exteriorization of the injury with
lateral duodenostomy and planned delayed
reconstruction.
STOMACH
Tips and pitfalls

The superior mesenteric vein and its branches are easily
injured with excessive traction during the Kocher and
Cattell–Braasch maneuvers.
Care should be taken during repairs and anastomoses
involving the second portion of the duodenum to identify
and preserve the ampulla of Vater.
Separation of the second portion of the duodenum from
the head of the pancreas results in ischemia and necrosis of
the duodenum.
During division of the ligament of Treitz, proceed carefully
to avoid injury to the superior mesenteric artery on the
Pylorus sutured closed right and the inferior mesenteric vein on the left.
Fig. 23.9(c). Pyloric exclusion. A 0 absorbable suture is utilized to close the Injuries of the medial aspect of the second portion of the
pylorus (circle). A gastrojejunostomy is then created using the previous
gastrotomy.
duodenum can be explored from within the lumen,
through a lateral duodenotomy.
In complex injuries, distal feeding access should be
Destructive injuries to the pancreatic head and duodenum considered through a feeding jejunostomy tube.
may require pancreaticoduodenectomy (Whipple Closed suction drains should be placed around, but not
procedure). directly overlying duodenal repairs.
197
Section 6 Abdomen
Liver injuries
Chapter
24 Kenji Inaba and Kelly Vogt
Surgical anatomy injury and are non-anatomical. However, the external

anatomical landmarks may be useful in planning
The liver is held in place by the following ligaments: operative maneuvers.
The falciform ligament, which attaches the liver to the
The plane between the center of the gallbladder and
anterior diaphragm and the anterior abdominal wall,
the inferior vena cava (IVC) runs along the middle
extending towards the umbilicus.
hepatic vein, and serves as the line of division between
The coronary ligament, which attaches the right lobe of the right and left lobes.
the liver to the diaphragm. The lateral extensions of the
The left lobe is divided by the falciform ligament into
coronary ligament form the triangular ligaments, right
the medial and lateral segments.
and left, which are also attached to the diaphragm.
Dissection along the falciform ligament should be
The anatomical division of the liver into the eight classic performed carefully, so as to avoid injury to the portal
Couinaud segments has no practical application in trauma,
venous supply to the medial segment of the left lobe.
where the resection planes are dictated by the extent of
Left hepatic vein Fig. 24.1. Surgical anatomy of the liver. The plane
Right hepatic vein between the gallbladder and inferior vena cava
Middle hepatic vein (IVC) (interrupted line) runs along the middle
Coronary ligament hepatic vein. Dissection along the falciform
ligament should be done carefully, so as to avoid
injury to the portal venous supply to the medial
segment of the left lobe.
Falciform ligament
Portal vein
IVC
198
Chapter 24. Liver injuries
The retrohepatic IVC is approximately 8–10 cm long and is the superior mesenteric artery. Alternatively, the left
partially embedded into the liver parenchyma. In hepatic artery may arise from the left gastric artery.
approximately 7% of individuals the IVC is completely The portal vein provides approximately 70% of hepatic
encircled by the liver. blood flow, and the remaining 50% of the hepatic
There are three major hepatic veins (right, middle, and oxygenation. It is formed by the confluence of the superior
left), as well as multiple accessory veins. The first 1–2 cm of mesenteric vein and the splenic vein behind the head of the
the major hepatic veins are extrahepatic, with the pancreas. The portal vein divides into right and left
remaining 8–10 cm intrahepatic. In approximately 70% of extrahepatic branches at the level of the liver parenchyma.
patients, the middle hepatic vein joins the left hepatic vein, The porta hepatis contains the hepatic artery (left),
near the IVC. common bile duct (right), and portal vein (posterior,
The common hepatic artery originates from the celiac between the common bile duct and the hepatic artery).
artery. It is responsible for approximately 30% of the The right hepatic duct is easier to expose after removal of
hepatic blood flow, but supplies 50% of the hepatic the gallbladder.
oxygenation. It branches into the left and right hepatic The left hepatic bile duct, the left hepatic artery, and the left
arteries at the liver hilum in the majority of patients. In an portal vein enter the under-surface of the liver near the
anatomical variant, the right hepatic artery may arise from falciform ligament.
(a) Fig. 24.2(a). The porta hepatis contains the

hepatic artery (left), common bile duct (right), and
portal vein (posterior, between the common bile
duct and the hepatic artery).
Common bile
duct
Portal vein
Gastroduodenal Common hepatic Celiac trunk

artery artery
199
Section 6: Abdomen
(b) Fig. 24.2(b). Structures of the portal triad

dissected out.
LIVER Common hepatic artery
Common bile duct
Portal vein
General principles simple surgical techniques, such as application of local

hemostatic agents, electro-coagulation, superficial
The liver is the most commonly injured intra-abdominal suturing, or drainage. The remaining 15%–20% of cases
solid organ. require more complex surgical techniques.
Most injuries to the liver do not require operative
intervention.
Angioembolization is an effective adjunct to the non- Special surgical instruments
operative management of high-grade liver injuries, A hybrid operating room suite with angioembolization
especially in patients with evidence of active extravasation capability is highly desirable.
on contrast-enhanced CT scan. After damage control A standard trauma laparotomy and thoracotomy tray,
packing of complex liver injuries operatively, which includes vascular instruments. A sternotomy set
angioembolization may also be an effective adjunct. should be available in case a median sternotomy is needed
Damage control procedures have revolutionized the for improved exposure of the retrohepatic IVC.
management of complex liver injuries and in appropriate A fixed self-retaining abdominal retractor, such as an
cases they should be considered early. Packing is the Omni-flex, Bookwalter or Gomez.
mainstay of damage control for the liver and will be An electrothermal bipolar vessel sealing system (LigaSure
expanded upon below. device) is desirable.
A contained stable retrohepatic hematoma should not be A surgical head light.
opened. If the hematoma is expanding or leaking, and it is
possible to control with packing alone, this technique should
be the operative treatment of choice. The operation should Positioning
then be terminated and the patient brought to the ICU for Supine position, with upper extremities abducted to 90
ongoing resuscitation. Angioembolization may be of use, degrees.
especially if there is associated parenchymal damage that Skin antiseptic preparation should include the chest,
was packed. The patient can return to the operating room abdomen, and groin.
for pack removal after complete physiological stabilization. Use upper and lower body warming devices.
Adequate mobilization of the liver, by division of the
falciform and coronary ligaments, is essential in the
management of posterolateral injuries. Incisions
If, during anterior retraction of the liver, bleeding from The initial incision should be a midline laparotomy. This
posterior to the liver worsens, this is suspicious for injury incision provides limited exposure to the posterior and
to the retrohepatic IVC or to the hepatic veins. lateral parts of the liver. Depending on the anatomical area,
In approximately 80%–85% of patients undergoing and the extent of the liver injury, additional incisions may
operation, the liver injury can be managed by relatively be required.
200
(a)
HEAD
Fig. 24.3. Liver exposure thorough a midline laparotomy. This incision

provides limited exposure to the posterior and lateral parts of the liver.
Fig. 24.4(a). Right subcostal transverse extension of the midline laparotomy
incision allows greater access to the right upper quadrant.
To obtain better access to posterolateral liver injuries, a

right subcostal incision may be required to “T-off” the
initial laparotomy.
A median sternotomy may be required to obtain access to
the intrapericardial segment of the inferior vena cava for thoracotomy, and dividing the diaphragm, leaving a cuff
vascular occlusion of the liver, or to the heart for placement so that the diaphragm can be reconstructed.
of an atrio-caval shunt. If the patient has a severe liver injury best handled by
If the patient has undergone a right thoracotomy, access to damage control packing, this should be recognized early,
the posterior liver and retrohepatic venous structures can and the abdominal wall and ligaments left intact to allow
best be obtained by joining the laparotomy to the for more effective packing.
201
Section 6: Abdomen
(b)
Fig. 24.4(b). Improved exposure of the posterolateral liver through combined

midline and right subcostal incisions. For additional exposure, laparotomy pads
can be placed between the posterior liver and the diaphragm.
Fig. 24.5. A median sternotomy may be added to

the midline laparotomy in cases requiring access to
the intrapericardial segment of the inferior vena
cava for vascular occlusion of the liver, or to the
heart for placement of an atrio-caval shunt.
HEART LIVER
DIAPHRAGM
202
Operative techniques (a)
The first step after entering the peritoneal cavity is to assess

the extent of the liver injury, and to examine for other
associated injuries.
Temporary control of liver bleeding may be achieved by
finger compression of the liver wound. If this is not
effective, cross-clamping of the porta hepatis structures
with a vascular clamp through the foramen of Winslow
(Pringle maneuver) decreases the vascular inflow to the
liver, and reduces bleeding.
Insert the index finger of the left hand into the foramen
of Winslow and then pinch down with your thumb.
This can later be replaced with a non-crushing vascular
clamp or a Rummel tourniquet.
The duration of time for which the Pringle maneuver
may be safely used is unknown, but occlusion up to
30 minutes rarely causes any problems. Fig. 24.7(a). Pringle maneuver. The index finger of the left hand is placed into
Failure to control hemorrhage with the Pringle the foramen of Winslow (arrow) and the porta hepatis structures are
maneuver suggests either aberrant anatomy, or compressed with the thumb. This can later be replaced with a non-crushing
vascular clamp or a Rummel tourniquet (portal vein: blue vessel loop; common
bleeding from the hepatic veins or retrohepatic bile duct: yellow vessel loop; hepatic artery: red vessel loop).
vena cava.
(b)
Rummel tourniquet
Fig. 24.6. Temporary control of liver bleeding may be achieved by finger
compression of the liver wound.
Adequate exposure of the liver is critical in the Fig. 24.7(b). Pringle maneuver with Rummel tourniquet around the porta
hepatis stuctures (portal vein: blue vessel loop; common bile duct: yellow vessel
management of severe injuries. The first step is to loop; hepatic artery: red vessel loop).
place three to four laparotomy pads behind the liver,
under the diaphragm, and retract the liver anteriorly and
inferiorly. If this maneuver does not provide adequate
exposure, the next step is mobilization of the liver by between two of your fingers and sharply divide the
taking down the falciform and coronary ligaments. avascular ligament.
During division of the falciform ligament, care should be Bleeding from deep liver lacerations can often be controlled
taken to avoid injury to the hepatic veins, as the dissection by direct suture-ligation or clipping of any major bleeders,
progresses posteriorly. To facilitate this in a rapid fashion, followed by deep, figure-of-eight, tension-free sutures,
place gentle pressure down on the liver with the falciform using 0-chromic on a large blunt-tip liver needle.
203
Section 6: Abdomen
Fig. 24.8. Division of the falciform ligament:

place gentle pressure down on the liver with the
falciform between two of your fingers and then
sharply divide this avascular ligament. Care should
be taken to avoid injury to the hepatic veins, as the
dissection progresses posteriorly.
Falciform ligament
LIVER
(LigaSure device). This technique is most effective for

peripherally located tracts.
For more centrally located tracts, a tractotomy will
require the division of a significant volume of normal
parenchyma leading to increased tissue at risk of
bleeding, especially in coagulopathic patients. An
alternative to the tractotomy is a damage control
tamponade using a balloon catheter. A Sengstaken and
Blakemore tube designed for esophageal varices, a large
Foley catheter, or a custom-made balloon from a
surgical glove can be used. If a Foley is used, several
may be required to fully fill the tract. Once the bleeding
is controlled, perihepatic damage control packing is
performed. The balloon is kept in place until the
patient’s physiology has normalized before re-
exploration and possible removal. Postoperative
angiographic evaluation should be considered.
Fig. 24.9. Bleeding control from deep liver laceration with figure-of-eight,
tension-free sutures and local hemostatics (circle).
Concerns regarding intrahepatic abscess or hemobilia

resulting from the placement of deep sutures have been
overstated. These complications can be managed by
percutaneous drainage or angiographic embolization. Inflated balloon
Omental packing of large liver wounds is useful for LIVER
filling in defects.
Severe bleeding from deep, bullet or knife tracts in the liver
can be controlled with tractotomy and direct bleeding
control or with the use of a balloon tamponade.
Packing of the tract with hemostatic agents or gauze is
usually not effective in controlling significant bleeding,
but can be tried first.
Tractotomy may be performed along the tract using
sequential firings of a linear stapler, finger fracture
techniques, and ligation of vessels and biliary branches, Fig. 24.10. Balloon tamponade of bleeding from deep, central knife
or with an electrothermal bipolar vessel sealing system wound tract.
204
Extensive parenchymal damage, usually due to severe (b)

blunt trauma or high-velocity gunshot wounds, is often
not amenable to deep suturing. Under these conditions,
the bleeding can be addressed with other techniques,
including perihepatic packing, liver resection, hepatic
artery ligation, total vascular liver isolation, and atrio-caval
shunting.
HEAD
In patients with compromised physiology and complex
injuries not amenable to rapid definitive hemostasis,
consider early damage control with perihepatic
packing.
The technique of the packing is important. The
presence of intact hepatic ligaments increases the
effectiveness of the tamponade and they should not
routinely be divided. Fig. 24.11(b). Gauze packing over the perihepatic mesh.
Commercially available local hemostatic products can
be used if available; however, the mainstay is the use of
laparotomy pads. If packing does not control the bleeding, it is essential
In suspected retrohepatic venous bleeding, the liver to unpack and look for major surgical bleeding. The
should be compressed posteriorly against the IVC, with patient should never leave the operating room if
no packs placed behind the liver. packing does not control the bleeding.
In order to avoid bleeding from the raw surface of the Following perihepatic packing, the abdomen should
liver during removal of the laparotomy pads at always be left open, using a temporary abdominal wall
reoperation, an absorbable mesh may be laid over the closure, because of the high risk of development of
raw surface of the liver, underneath the packing. The abdominal compartment syndrome.
mesh is permanently left in place when the packing is Early postoperative angiographic evaluation for
removed. possible sites of bleeding should be considered in all
cases undergoing liver packing. The availability of a
hybrid operating room suite facilitates the procedure.
(a) The perihepatic packing should be removed as soon as
the patient stabilizes physiologically, which usually
occurs within 24 to 36 hours.
Non-anatomical liver resection may be needed in cases with

devitalized liver parenchyma or persistent bleeding that cannot
be controlled with suturing or perihepatic packing. In general,
major anatomic hepatic resections are rarely indicated and
should be reserved for destructive parenchymal injuries where
perihepatic packing is not effective in controlling the
hemorrhage.
Non-anatomical resections can be performed with
finger dissection of the parenchyma, with suture
ligation of vessels and biliary branches, or with the use
of an electrothermal bipolar vessel sealing system
(LigaSure device).
Selective hepatic artery occlusion with a hemostatic clip may

be useful in rare cases. The artery should be clipped only if
Fig. 24.11(a). Absorbable mesh may be placed over the surface of the liver, temporary occlusion results in reduction of the bleeding.
under the packing gauze. The mesh is permanently left in place when the The combination of hepatic artery ligation, parenchyma
packing is removed, after the patient stabilizes. This approach reduces the risk of
recurrent bleeding during the gauze removal. injury, and hypotension, often leads to hepatic necrosis.
205
Section 6: Abdomen
(a) (b)
Fig. 24.12(a). Grade 4 injury to the right lobe of the liver, undergoing a non- Fig. 24.12(b). Completion of non-anatomical resection of part of the right
anatomical resection. Major vessels and bile ducts are individually ligated and lobe (circle). The edges may be approximated with interrupted figure-of-eight
divided. sutures. Circle demonstrates the cut edge of the resected liver.
digitoclasia
Fig. 24.13. Isolation and ligation or application of

a vascular clip on one of the hepatic arteries may
be useful in some cases. This approach should be
considered only if temporary occlusion of the
artery is effective in controlling the bleeding.
LIVER
Left hepatic artery

Right hepatic artery
Common hepatic
artery
206
Fig. 24.14. The combination of hepatic artery

ligation, parenchyma injury, and hypotension,
often leads to hepatic necrosis (arrows).
Ligation can also be considered for the rare occasion The atriocaval shunt reduces retrohepatic venous
where there is direct injury to the hepatic artery. bleeding, but does not achieve complete cessation of the
Shunting is an alternative damage control option that bleeding.
may be considered, depending on the size and location The experience of the surgical team and the timing
of injury. of the shunt are critical factors in determining
outcome. It should be considered early, before the
In cases of ineffective perihepatic packing when the injury is development of major coagulopathy and severe
not amenable to resection, temporary control of the bleeding hypothermia.
can be achieved by using vascular isolation of the liver. This
will facilitate visualization and possible repair of the area of
bleeding.
Vascular isolation consists of cross-clamping the aorta Extrahepatic biliary tract injuries
below the diaphragm, the suprahepatic and infraheptic Most injuries to the gallbladder are best treated by
IVC, and the porta hepatis. cholecystectomy, although cholecystorrhaphy with
Clamping the aorta is essential and should be done first absorbable sutures has been recommended for small
in order to prevent hypovolemic cardiac arrest. wounds.
Suprahepatic cross-clamping of the IVC can be Injuries to the common bile duct (CBD) are difficult to
performed by applying a vascular clamp on the IVC, repair because of the small duct size in young, healthy
between the diaphragm and the dome of the liver. individuals, and a high incidence of postoperative stenosis
Practically, however, total hepatic vascular isolation is can be expected.
very rarely necessary because of the increased use of Complete CBD transection is best managed with a
packing and is employed only for very severe injuries, Roux-en-Y biliary enteric anastomosis.
often where the retrohepatic IVC or hepatic veins are Incomplete transection of the CBD may be repaired
injured. In these patients, attempting to place a clamp primarily. Insertion of a T-tube through a separate
on the IVC in this location is extremely difficult due to choledochotomy and repair of the duct injury over the
the hematoma and bleeding, and there is a high T-tube can reduce the risk of stenosis.
probability of worsening the injury by clamping here.
In patients presenting in extremis no definitive CBD
Control of the intrapericardial IVC through a limited
reconstruction should be attempted. In these cases the
lower sternotomy may be preferable in this situation.
CBD can be ligated. Alternatively, a catheter can be
The use of atriocaval shunting may be considered in selected placed into the proximal duct and brought out through
complex retrohepatic venous injuries that cannot be managed the skin for external drainage. Reconstruction with a
by other less aggressive approaches. bilioenteric anastomosis is performed after patient
(Details of the atriocaval shunt are shown in Chapter 30.) stabilization.
207
Section 6: Abdomen
Postoperative complications hemostatic agents, electro-coagulation, superficial

suturing, or drainage. The remaining 15%–20% of cases
The incidence of postoperative liver-related complications require more complex surgical techniques.
in surviving patients with severe liver injuries (grades III
Exposure of posterolateral liver injuries is difficult through
to V) has been reported to be as high as 50%.
the standard midline laparotomy. Addition of a right
These complications include early or late hemorrhage, liver subcostal incision, division of the liver ligaments and
necrosis, liver abscess, biloma, biliary fistula, false
placement of laparotomy sponges behind the liver, greatly
aneurysm, arteriovenous fistula, hemobilia, and
improve the exposure.
intrahepatic biliary strictures.
Perihepatic packing and angioembolization are significant
The timing of clinical presentation of liver-related surgical advances in the management of complex liver
complications may vary from a few days to many months.
injuries. Consider these options early, before the patient is
Some complications such as biloma, false aneurysm, or
in extremis.
arteriovenous fistula may remain asymptomatic only to
For effective packing of suspected retrohepatic venous
manifest as potentially life-threatening complications at a
bleeding, no packs should be placed between the liver and
later stage.
the IVC. The liver should be compressed posteriorly,
against the IVC and the hepatic veins.
Tips and pitfalls Packs placed too tightly may occlude the inferior vena cava
The anatomic division of the liver into the eight classic and impair venous return leading to hemodynamic
Couinaud segments is practical in elective liver surgery, but instability and kidney dysfunction.
not in trauma. Stable retrohepatic hematomas should not be explored. In
For approximately 80%–85% of patients undergoing cases with bleeding, if packing is effective, do not pursue
operation, the liver injury can be managed by relatively further exploration.
simple surgical techniques, such as application of local Use closed-suction drains in all complex injuries.
208
Section 6 Abdomen
Splenic injuries
Chapter
25 Demetrios Demetriades and Matthew D. Tadlock
Surgical anatomy of the left kidney and extends to the splenic hilum, as a
The spleen lies under the ninth to eleventh ribs, under two-layered fold that invests the tail of the pancreas and
the diaphragm. It is lateral to the stomach and splenic vessels. The splenophrenic ligament connects the
anterosuperior to the left kidney. The tail of the pancreas posteromedial part of the spleen to the diaphragm, and the
is in close anatomical proximity to the splenic hilum splenocolic ligament connects the inferior pole of the
and amenable to injury during splenectomy or hilar spleen to the splenic flexure of the colon. The splenogastric
clamping. ligament is the only vascular ligament and contains five to
The spleen is held in place by four ligaments, which seven short gastric vessels, which originate from the distal
include the splenophrenic and splenorenal ligaments splenic artery and enter the greater curvature of the
posterolaterally, the splenogastric ligament medially, and stomach. Excessive retraction of the splenic flexure or the
the splenocolic ligament inferiorly. The splenorenal gastrosplenic ligaments can easily tear the splenic capsule
ligament begins at the anterior surface of Gerota’s fascia and cause troublesome bleeding.
(a) Fig. 25.1(a). The spleen is held in place by four

ligaments: the splenophrenic and splenorenal
ligaments posterolaterally, the splenogastric
Gastrosplenic medially, and the splenocolic inferiorly. Medial
ligament rotation of the spleen (inset) exposes the
splenophrenic and splenorenal ligaments.
Splenorenal
ligament
Splenocolic ligament
209
Section 6: Abdomen
(b) (a)
Liver
Splenorenal ligament
Diaphragm
Spleen
Anterior surface of the

Gerota’s fascia
(b)
Spleen Diaphragm
Splenorenal ligament
Anterior surface of the

Gerota’s fascia
Fig. 25.1(b). Undue traction on the spleen, the stomach, or the colon may Fig. 25.2(a),(b). Medial rotation of the spleen exposes the splenorenal
cause capsular avulsion and bleeding. ligament, which begins at the anterior surface of the Gerota’s fascia of the left
kidney and extends to the splenic hilum.
210
Chapter 25. Splenic injuries
Fig. 25.3. The splenocolic ligament connects the

inferior pole of the spleen to the splenic flexure of
the colon and is avascular. Excessive traction may
Inferior pole of the spleen cause capsular avulsion and bleeding.
Splenocolic ligament
lon
Co
Most people, approximately 70%, have a distributed or

medusa-like branching that occurs 5–10 cm from the
Liver
spleen. Simple branching occurs in approximately 30%,
1–2 cm from the spleen.
Diaphragm The splenic vein courses posterior and inferior to the
splenic artery, receives the inferior mesenteric vein,
Stomach and joins the superior mesenteric vein to form the
portal vein.
General principles
Gastrosplenic ligament The spleen is the second most commonly injured
with short gastric vessels abdominal solid organ after blunt trauma and the
second most commonly injured after penetrating
trauma.
Nearly 80% of patients with splenic injury after blunt
Fig. 25.4. The stomach is retracted medially and the spleen laterally, revealing trauma can be managed non-operatively, but only if they
the gastrosplenic ligament and the short gastric vessels.
are hemodynamically stable with a stable hemoglobin and
without peritonitis. Non-operative management of splenic
injuries is ill-advised in patients with a significant injury
The mobility of the spleen depends on the architecture of
burden, coagulopathy, or a severe traumatic brain injury.
these ligaments. In patients with short and well-developed
ligaments mobilization is more difficult and requires Angioembolization is an adjunct to the non-operative
management of high-grade splenic injuries, especially in
careful dissection in order to avoid further
patients with evidence of active extravasation on contrast-
splenic damage.
enhanced CT scan.
The splenic hilum contains the splenic artery and vein and
is often intimately associated with the tail of the pancreas. All patients who undergo emergent splenectomy should
receive vaccinations for encapsulated organisms prior to
The extent of the space between the tail of the pancreas and
hospital discharge.
the splenic hilum varies from person to person.
The splenic artery is a branch of the celiac axis that courses
superior to the pancreas towards the splenic hilum where it Special surgical instruments
divides into an upper and lower pole artery. There is A standard trauma laparotomy tray, which includes
significant variability in where this branching occurs. vascular instruments.
211
Section 6: Abdomen
A fixed self-retaining retractor such as a Bookwalter (b)

retractor is very helpful.
An electrothermal bipolar vessel sealing system device Left diaphragm
(LigaSure device) is desirable.
An absorbable mesh or pre-formed mesh splenic pouch
should be available in cases where splenic preservation is to
be attempted.
Spleen
Positioning and incision
The patient should be placed in the supine position
with arms out and prepped from nipples to knees.
For trauma, entry into the abdomen should be through
a midline incision, starting high, at the xiphoid
process.
Fig. 25.5(b). With the surgeon’s left hand, the spleen is gently rotated
Exposure medially and downward to facilitate the placement of laparotomy pads.
Upon entry into the peritoneal cavity, the surgeon often
encounters a significant amount of blood. The blood
should be removed quickly and the left upper quadrant (c)
packed with laparotomy pads, to temporarily control the
bleeding.
The next step is full exposure and inspection of the spleen
in order to plan the definitive management of the injury.
The surgeon should slide his hand gently over the
posterolateral surface of the spleen and exert slight medial
and downward traction. Three or four laparotomy pads are
then placed under the left diaphragm and behind the
spleen, providing excellent exposure.
The surgeon should be gentle during exposure of the spleen
because undue traction on the stomach or the splenic
(a)
Fig. 25.5(c). Laparotomy pads are placed above and behind the spleen, to
keep the spleen in a downward and medial position. Note the significantly
improved exposure.
flexure of the colon or excessive medial rotation of the

Diaphragm
spleen may cause avulsion of the delicate splenic capsule,
aggravating the bleeding and decreasing the possibility of
Spleen splenic preservation.
Profuse bleeding can temporarily be controlled with digital
compression of the hilum between the second and third
fingers of the surgeon’s left hand or by direct digital
compression of the splenic parenchyma. A vascular clamp
can also be placed across the hilum, taking care not to
injure the tail of the pancreas.
Mobilization of the spleen is not necessary for simple
repairs and in some cases it may worsen the splenic injury.
Fig. 25.5(a)–(c). View of the spleen, deep in the left hypochondrium from the
right side of the operating room table. Note the deep and posterior position of
the spleen, which makes exposure difficult.
212
In order to facilitate splenectomy or complex splenic system such as the LigaSure device may be used as a safe
preservation operations using splenic mesh or partial and faster alternative to vessel ligation and division.
splenectomy, the spleen should be adequately mobilized. The The spleen now is attached only by the splenic vessels,
first step is division of the splenophrenic and splenorenal along with the tail of the pancreas, at the hilum.
ligaments posterolaterally. These ligaments are avascular and
can be divided sharply. The next step is the en-bloc medial (a)
mobilization of the spleen and the tail of the pancreas.
Mobilization of the tail of the pancreas may not be necessary
in patients with a short pancreas and a long distance between
the tail and the hilum. The next step is division of the
vascular gastrosplenic ligament, as far away from the
stomach as possible, in order to avoid injury or ischemic
Hilum of spleen
necrosis of the gastric wall. The final step is division of the
splenocolic ligament. Although this stepped approach for the
mobilization of the spleen is applicable to most patients, the
surgeon should have in mind that the order of taking down
the splenic ligaments should be flexible and determined by
the local anatomy, and may vary from patient to patient. Ruptured lower pole
For the patient with a partially avulsed spleen that is actively of spleen
hemorrhaging, rapid hilar vascular control takes precedence
over meticulous ligament identification and division.
(b)
Liver
Splenogastric
ligament Splenic artery Splenic vein
Fig. 25.6. The spleen is mobilized, reflected medially, and the splenic vessels
dissected.
Once adequate exposure is obtained, the salvageability of

the spleen is assessed.
Splenectomy
The first step is adequate mobilization of the spleen and
delivery of the spleen towards the midline. Temporary
bleeding control and division of the ligaments are
performed as described. The short gastric vessels in the
gastrosplenic ligament should be ligated away from the Fig. 25.7(a),(b). After division of the splenic ligaments and medial rotation,
the spleen remains attached only by the splenic vessels. Bleeding control is
stomach, in order to avoid damage or ischemic necrosis of achieved by compressing the hilar structures between the fingers. The vessels
the gastric wall. An electrothermal bipolar vessel sealing are individually ligated and divided (b). Splenectomy specimen (b).
213
Section 6: Abdomen
The splenic artery and vein should be individually ligated of the distal pancreas may need to be resected to
as close to the hilum as possible to avoid injuring the safely perform the splenectomy. This can be done
pancreas. Use of an electrothermal bipolar vessel sealing with a TA stapling device or an electrothermal bipolar
system is an alternative to ligation and division of the vessel sealing system. In these cases care should be
vessels. taken to ensure hemostasis of the superior pancreatic
Occasionally, the splenic hilum and tail of the artery that runs along the superior portion of
pancreas are so intimately related that a small portion the pancreas.
(a) (b)
Spleen
Tail of
pancreas
Fig. 25.8(a),(b). Stapled splenectomy technique. Sometimes the tail of the pancreas is so intimately related to the splenic hilum, that it may be necessary to
remove a small part of the pancreas with the spleen. A stapled en-masse resection is an effective resection technique. (The splenic artery is shown encircled with a
red vessel loop and the splenic vein with a blue vessel loop.) The photo shows medial mobilization of the spleen and pancreas and application of the TA stapler on
the tail of the pancreas. Circle shows staple line of the distal pancreas after distal pancreatectomy.
214
Mass ligation of the artery and vein together may be (a)

considered in unstable patients, although there is
concern about the rare complication of arteriovenous
fistula.
After the removal of the spleen, meticulous hemostasis
should be performed. The most common sites of
incomplete hemostasis are the areas near the tail of the
pancreas and the greater curvature of the stomach, at the
insertion of the short gastric vessels. The stomach should
be inspected for any ischemic damage. Likewise, the tail of
the pancreas should also be examined for any iatrogenic
injury.
In a damage control setting, there is no role for spleen
preserving operations. The splenic bed is at risk of
bleeding and should be packed with several
laparotomy pads.
Although the routine placement of closed suction drains in Fig. 25.9(a). Digital compression of the injured spleen by the assistant
provides temporary bleeding control, while the surgeon places the sutures.
the splenic bed is a controversial issue, it is advisable to
place a closed drain in cases where there is concern about
incomplete hemostasis or possible injury to the tail of the
(b)
pancreas.
Splenorrhaphy
The size, site, and shape of the splenic injury and the
hemodynamic condition of the patient will determine the
feasibility of a spleen-preserving operation.
For capsular avulsions or superficial parenchymal
lacerations, there is no need for full splenic mobilization
with division of the splenic ligaments. Placement of two to
three laparotomy pads behind the spleen usually provides
adequate exposure.
For complex repairs, full mobilization of the spleen, as
described above, may be necessary.
In cases with avulsion of the splenic capsule or minor
lacerations, hemostasis can be achieved with local
hemostatic agents.
Superficial lacerations may be repaired with figure-of-eight
or horizontal mattress absorbable sutures, on a blunt
liver needle. The presence of an intact splenic capsule
makes the placement of the sutures technically easier,
because it prevents tearing of the parenchyma. If the
parenchyma is fragile and does not hold sutures, pledgets
may be used.
Fig. 25.9(b). Alternatively, the surgeon compresses the spleen with the non-
dominant hand and places the sutures with the dominant hand.
215
Section 6: Abdomen
In deep lacerations with active bleeding, temporary (b)

control may be achieved by finger compression of the
injured site or the hilum. Any major bleeders are suture
ligated individually and the laceration is then repaired
with interrupted figure-of-eight sutures, as described
above. Failure to individually ligate any major bleeders
before suturing a deep laceration may result in
intrasplenic hematoma or false aneurysm. An omental
patch may be sutured into areas with tissue loss.
Partial splenectomy
A partial splenectomy is possible because of the segmental
blood supply of the spleen, with the vessels traveling in a
parallel fashion. It should be considered in injuries
localized to either the upper or lower pole of the spleen.
Full splenic mobilization, as described above, is essential
before attempting partial splenic resection. Fig. 25.10(b). Vertical mattress sutures with pledgets may be used for
persistent oozing from the cut edge.
If the individual vessels to the injured pole can be
identified, they should be ligated at the hilum before
entering the spleen, for better hemostasis.
A capsular incision is made with electrocautery, parallel to
(a) the lobar arteries. Using blunt finger dissection or fine-
tipped suction, the underlying parenchyma of the avascular
tissues is divided and individual intrasplenic vessels are
identified and ligated with a 3–0 or 4–0 silk. Alternatively
an electrothermal bipolar vessel sealing system (LigaSure
device) or a TA stapling device may be used.
(a)
Fig. 25.10(a). Partial splenectomy is a viable option in splenic injuries

involving the poles. The procedure may be performed with finger dissection Fig. 25.11(a)–(c). Partial splenectomy of the lower pole with a TA-90 stapler;
and ligation of individual intrasplenic vessels or electrothermal bipolar vessel injury to the inferior pole of the spleen, not amenable to repair (a). Application
sealing system (LigaSure device) or a TA stapling device. Ligation of segmental of TA-90 stapler proximal to the injury’s inferior pole (b). Completion of partial
vessels in the hilum (arrow) reduce bleeding. If there is persistent oozing from splenectomy with complete hemostasis (c).
the cut edges, vertical mattress sutures may be applied, with or without
pledgets.
216
(b) (a)
(c)
(b)
Fig. 25.11(a)–(c). (cont.)
If there is persistent oozing from the cut edges, hemostatic

vertical mattress sutures may be applied, with or without
pledgets.
Splenic mesh
An absorbable mesh can also be utilized for splenic salvage,
in cases with multiple stellate parenchymal injuries or with Fig. 25.12(a),(b). Application of a splenic mesh may be a good adjunct
in splenic preservation operations, in multiple stellate parenchymal
extensive avulsion of the splenic capsule. lacerations, or in extensive capsular avulsion (a). Commercially available
Bean-shaped mesh pouches are commercially available, or splenic mesh (b).
a mesh wrap can be constructed by the surgeon. Local
hemostatic agents may be used as adjuncts to the mesh.
217
Section 6: Abdomen
Tips and pitfalls splenic tissue distally. If there is concern about damage to
the stomach, it is advisable to oversew the area with
Non-operative management of severe blunt splenic injuries Lembert sutures.
in patients with traumatic head injury or coagulopathy is
During splenectomy, the splenic vessels should be ligated
generally not recommended.
very close to the spleen to avoid injury to the tail of the
Splenic salvage is a reasonable option in stable patients, if pancreas. If a rim of pancreatic tissue has to be removed
the injury is amenable to simple repair, splenic mesh, or
with the spleen, suture-ligate or use an electrothermal
partial splenectomy. In unstable or coagulopathic patients,
bipolar vessel sealing system to prevent pancreatic leaks or
splenectomy is the procedure of choice.
bleeding from the superior pancreatic artery.
Full mobilization of the spleen is mandatory before
The most common sites of persistent postoperative
attempting splenorrhaphy of deep or complex lacerations,
bleeding are the areas near the tail of the pancreas from the
placement of a splenic mesh, or a partial splenectomy.
superior pancreatic artery and at the insertion of the short
Mobilization of the spleen improves the exposure, but it
gastric vessels into the stomach.
has the potential of making the injury worse, if done
All severe splenic injuries managed with splenic
incorrectly.
preservation should undergo a postoperative CT scan with
During splenectomy, ligation of the short gastric vessels intravenous contrast to rule out false aneurysms or
should be performed close to the spleen to avoid damage to
arteriovenous fistulas.
the greater curvature of the stomach. These vessels can be
Remember to vaccinate splenectomy patients for
very short and there is little or no space between the
encapsulated organisms prior to discharge.
stomach and the spleen. In these cases leave a thin rim of
218
Section 6 Abdomen
Pancreas
Chapter
26 Demetrios Demetriades, Emilie Joos, and George Velmahos
Surgical anatomy the anterior and posterior pancreaticoduodenal

arcades. These arcades lie on the surface of the
The pancreas lies transversely in the retroperitoneum, at pancreas, close to the duodenal loop. Any attempts to
the L1–L2 vertebral level, between the duodenum and the
separate the two organs result in ischemia of the
hilum of the spleen.
duodenum.
The head of the pancreas lies over the inferior vena cava
The body and tail of the pancreas receive their blood
(IVC), right renal hilum, and the left renal vein at its
supply mainly from the splenic artery. The splenic
junction with the IVC.
artery originates from the celiac artery and courses to
The uncinate process extends to the left and wraps from the left, along the superior border of the pancreas. It
around the superior mesenteric vessels. It is in close follows a tortuous route, with parts of it looping above
proximity to the inferior pancreaticoduodenal artery. and below the superior border of the pancreas. It gives
The neck of the pancreas lies over the superior mesenteric numerous small and short branches to the body and tail
vessels and the proximal portal vein. The space between the of the pancreas.
neck and the superior mesenteric vessels is avascular and
The splenic vein courses from left to right, superiorly
allows blunt dissection without bleeding. The area to either and posteriorly to the upper border of the pancreas,
side of the midline is vascular and should be avoided. inferiorly to the splenic artery. It is not tortuous like the
The body of the pancreas lies over the suprarenal aorta and artery. It joins the superior mesenteric vein, at a right
the left renal vessels. It is intimately related to the splenic angle, behind the neck of the pancreas, to form the
artery and vein. portal vein. The inferior mesenteric vein crosses behind
The major pancreatic duct (Wirsung duct) traverses the the body of the pancreas and drains into the
entire length of the pancreas and drains into the ampulla of splenic vein.
Vater, approximately 8 cm below the pylorus. The lesser The portal vein is formed by the junction of the superior
duct of Santorini branches off the superior aspect of the mesenteric and splenic veins, in front of the inferior vena
major duct, at the level of the neck of the pancreas, and cava and behind the neck of the pancreas.
drains separately into the duodenum, approximately
The common bile duct (CBD) courses posterior to the
2–3 cm proximal to the ampulla of Vater. first part of the duodenum, in front of the portal vein,
The pancreas receives its blood supply from both the celiac continues behind the head of the pancreas, often
artery and the superior mesenteric artery. partially covered by pancreatic tissue, and drains into
The head of the pancreas and the proximal part the ampulla of Vater, in the second part of the
of the duodenum receive their blood supply from duodenum.
219
Section 6: Abdomen
Splenic artery Fig. 26.1. Surgical anatomy of the pancreas.

The head of the pancreas and the proximal part
Portal vein of the duodenum share blood supply from the
anterior and posterior pancreaticoduodenal
arcades. (SMA ¼ superior mesenteric artery,
SMV ¼ SMA ¼ superior mesenteric vein.)
Splenic vein
Inferior
mesenteric vein
Anterior
pancreaticoduodenal
arcade
SMV
SMA
General principles Pancreaticoduodenectomy should rarely be considered

because of its complexity and the associated high
The management of pancreatic trauma is determined by
morbidity and mortality. It should be considered
the presence or absence of pancreatic duct injury. Patients
primarily in cases with severe combined
with pancreatic contusions or lacerations without duct
pancreaticoduodenal trauma.
involvement may be managed non-operatively. If these
injuries are discovered during the operation, drainage with In cases with pancreatic injury selected for non-operative
management, evaluation by means of endoscopic
closed suction drain is usually sufficient. Conversely,
retrograde cholangiopancreatography (ERCP) or
almost all patients with pancreatic duct transection require
magnetic resonance cholangiopancreatography (MRCP)
operative management and pancreatic resection.
is important in order to assess the integrity of the
The pancreas is surgically divided into a distal and proximal
pancreatic duct. In addition, for selected cases, ERCP
part. The distal pancreas consists of all pancreatic tissue (body
can be used for therapeutic stent placement.
and tail) to the left of the superior mesenteric vessels. The
proximal pancreas is composed of all pancreatic tissue (head Missed pancreatic injuries with ductal involvement may
result in complications such as pancreatitis, pancreatic
and neck) to the right of the superior mesenteric vessels.
ascites, pancreatic pseudocyst, abscess, or erosion of the
In distal pancreatic injuries involving the pancreatic adjacent vessels with life-threatening bleeding.
duct, a distal pancreatectomy is the procedure of choice. Pancreatic injuries without ductal involvement rarely
A spleen-preserving distal pancreatectomy can be cause significant problems and do not require operation.
considered in stable patients. However, in the presence
of severe associated injuries or hemodynamic instability
a distal pancreatectomy with splenectomy should be Special surgical instruments
performed because it is a much faster and easier Standard exploratory laparotomy tray can be used for this
procedure. approach.
Distal pancreatectomy rarely results in permanent Self-retaining Bookwalter or Omni-flex retractor can
diabetes or in pancreatic exocrine insufficiency. greatly facilitate surgical exposure.
Hyperglycemia may be observed in the early postoperative Head light.
period, but it usually resolves spontaneously.
For injuries involving the head of the pancreas, if the
integrity of the duct cannot be confirmed, pancreatic
Positioning
drainage alone should be considered. Radical resections The patient should be in supine position, with arms
should be avoided because of the associated high abducted at 90 degrees. Preparation and draping should be
morbidity and mortality. done in the usual fashion.
Freeing of the lateral aspect of the head of the pancreas
from the duodenum results in ischemia of the Incision
duodenum and it should never be considered. A standard midline trauma laparotomy incision.
220
Chapter 26. Pancreas
Exposure the pancreas, are mobilized en-bloc from their

retroperitoneal position and rotated to the left. This
A pancreatic injury should be suspected by the presence of
exposure allows inspection and palpation of the anterior
fluid collection or hematoma in the lesser sac, and by fat
and posterior surfaces of the head and uncinate process.
necrosis of the surrounding tissues.
In penetrating injuries, associated vascular injuries to the
Most of the pancreas can be exposed through the lesser
superior mesenteric vessels or the portal vein are common
sac. The stomach is retracted upward and toward the
and hemostasis is difficult. In these cases, division of the
patient’s head and the transverse colon is retracted
neck of the pancreas with a stapling device may achieve
towards the pelvis. The gastrocolic ligament is divided,
adequate exposure of the vessels with a stapling device.
starting from the left side where the ligament is usually
This can be done by dissecting the avascular plane between
thin and transparent. An electrothermal bipolar vessel
the posterior surface of the neck of the pancreas and the
sealing system (LigaSure device) may be used as a safe
portal vein and the superior mesenteric vessels, creating a
and rapid alternative to vessel ligation and division. The
tunnel to pass the stapler. Care should be taken to stay in
lesser sac is then entered and any attachments between
the avascular midline to avoid bleeding.
the pancreas and the posterior wall of the stomach are
divided. This approach exposes the anterior, superior, All peripancreatic hematomas should be explored to evaluate
the integrity of the pancreatic duct. However, some surgeons
and inferior surfaces of the body and tail of the
recommend that isolated hematomas in the head of the
pancreas.
pancreas with no associated injuries may be left undisturbed,
The posterior pancreas can be inspected by incising the
because the duct in this area is deep in the parenchyma and
peritoneum over the inferior border of the pancreas and by
the surgical management if undertaken, would include
gentle upward retraction. In cases where a detailed
major resections, such as pancreaticoduodenectomy. These
examination of the posterior distal pancreas is required, the
patients should be evaluated postoperatively using MRCP or
spleen and tail of the pancreas are mobilized and retracted
ERCP. In cases with ductal injury, an ERCP-placed stent
medially en-bloc (see Chapter 25).
should be considered.
The head and uncinate process of the pancreas can be
Normal size pancreatic ducts may be difficult to visualize.
exposed with an extended Kocher maneuver. The hepatic
The use of magnifying glasses and administration of
flexure of the colon is mobilized and retracted medially and
secretin may facilitate visualization of smaller ductal
inferiorly. The second and third portion of the duodenum
injuries.
comes into view, and the peritoneum over the lateral wall
of the duodenum is incised. Using blunt dissection, the Radiological and endoscopic methods of intraoperative
pancreatography are rarely used in trauma.
second and third part of the duodenum, and the head of
(a) Fig. 26.2(a). Most of the pancreas can be

exposed through the lesser sac, by dividing the
gastrocolic ligament.
Lesser omentum
Stomach
Gastro-colic ligament
Transverse colon
221
Section 6: Abdomen
(b) Fig. 26.2(b). Opening of the lesser sac: the

stomach is retracted upward and toward the
patient’s head and the transverse colon is retracted
toward the pelvis. The gastrocolic ligament is
divided, starting from the left side where the
ligament is usually thin and transparent.
Stomach
Gastrocolic ligament
(avascular part)
Lesser sac
Transverse
colon
(a) (b)
Stomach
(Posterior wall)
Posterior wall
of the stomach
Pancreas
Pancreas
SMA
SMV
Transverse colon Fig. 26.3(b). Complete exposure of the body and tail of the pancreas, after
opening the lesser sac and dividing any attachments between the posterior
wall of the stomach and the pancreas (SMA ¼ superior mesenteric artery, SMV
Fig. 26.3(a). After entering the lesser sac, any attachments between the ¼ superior mesenteric vein.)
pancreas and the posterior wall of the stomach (circle) are divided.
222
(a) (b)
Liver
Posterior HEAD
head of pancreas OF PANCREAS DUODENUM
Left renal
vein
IVC
IVC Left renal vein
Fig. 26.4(a),(b). Kocher maneuver: the posterior aspect of the head of the pancreas is exposed after medial rotation of the second portion of the duodenum. The
IVC and left renal vein are directly under the head of the pancreas.
(a) Fig. 26.5(a). Exposure of the superior mesenteric

vessels and the portal vein: division of the neck of
the pancreas with a stapling device. The stapling
device should be placed in the avascular plane
between the posterior surface of the neck of the
pancreas and the portal vein and the superior
mesenteric vessels.
Portal vein
Stapling device behind
neck of pancreas
Pancreatic tail
223
Section 6: Abdomen
(b) Fig. 26.5(b). Exposure of the superior mesenteric

vessels and the portal vein after division of the neck
Portal vein Celiac artery of the pancreas with a stapling device.
Splenic artery
Splenic vein
Inferior
mesenteric vein
Anterior
pancreaticoduodenal
arcade SMA
SMV
Management of pancreatic injuries Pancreatic injuries to the left of the superior mesenteric
vessels are best treated by distal pancreatectomy, often en-
Low-grade injuries without ductal injury are best managed
bloc with the spleen. The first step is to mobilize the body
with conservative debridement of non-viable tissue,
or tail of the pancreas, starting at the point of the injury.
hemostasis, and external drainage with closed suction
The peritoneum at the inferior border of the pancreas is
drains. Repair of the pancreatic capsule is possible,
incised and the plane behind the pancreas is developed
although it is controversial because of concerns about
using blunt dissection, taking care to avoid injury to the
increased risk of pseudocyst formation. Diffuse bleeding
splenic vessels, which are near the superior border and
may be managed with application of topical hemostatics
behind the pancreas. A vessel loop is then placed around
and tissue glue.
the pancreas. The resection of the pancreas is performed
High-grade injuries with ductal involvement or associated just proximal to the injury, through healthy tissues, using a
severe duodenal injuries require more complex procedures.
GIA or TA stapling device (see Fig. 26.5 a,b). If the
The choice of procedure depends on the hemodynamic
proximal end of the pancreatic duct is visible, it should be
condition of the patient, the site of the pancreatic injury
suture ligated with figure-of-eight non-absorbable sutures.
(head and neck versus tail of the pancreas), and the
The splenic artery and vein are then individually suture
experience of the surgeon.
ligated with figure-of-eight sutures. The pancreatectomy is
(a) Fig. 26.6(a). Technique of distal pancreatectomy:

after mobilization of the tail, the splenic artery and
vein are individually suture-ligated.
Splenic vessels
Tail of pancreas
Body of pancreas
224
(b) Fig. 26.6(b). Mobilization of the pancreatic tail

and the spleen.
Pancreas
Spleen
(c)
(a)
Body of pancreas
(b)
Stomach
Pancreas
Division of pancreas
Fig. 26.7(a),(b). Placement of TA stapling device and division of the body of Fig. 26.7(c). The pancreatic stump is oversewn (circle) with non-absorbable
the pancreas. sutures.
225
Section 6: Abdomen
(d) (a)
Fig. 26.7(d). En-bloc distal pancreatectomy and splenectomy.
completed by mobilizing the pancreas distally towards the

spleen. After the dissection reaches the hilum of the spleen,
the spleen is mobilized by dividing the vascular
gastrosplenic ligament first, followed by division of the
splenocolic, splenorenal, and splenodiaphragmatic
ligaments (see Chapter 25). An alternative aproach for
distal pancreatectomy is to start with mobilization of the
spleen, en-bloc medial rotation of the spleen with the tail of
the pancreas and a stapled resection proximal to the site of
injury.
Distal pancreatectomy with splenic preservation may be
considered in selected hemodynamically stable patients,
especially in children. The peritoneum is incised at the
inferior border of the pancreas, near the area of the injury,
and the surgeon dissects the plane behind the pancreas with
the index finger or a right-angle forceps. A vessel loop is Fig. 26.8(a). Oversewn proximal pancreatic stump and distal Roux-en-Y end-
applied around the pancreas and the splenic artery and vein to-end pancreaticojejunostomy.
are dissected free, taking care to clip or ligate and divide the
numerous small branches to the pancreatic parenchyma.
When the dissection reaches the splenic hilum, the
(b)
pancreas is removed.
Pancreatic resection extending to the right of the neck may
lead to diabetes and exocrine insufficiency. Preservation
of at least 1 cm of pancreatic tissue from the duodenal wall
is important in order to maintain the blood supply to the Distal
duodenum and avoid ischemic necrosis. In these cases, after pancreas
debridement of any damaged tissue, the distal pancreas may
be preserved and anastomosed to a Roux-en-Y jejunal loop,
using an end-to-end pancreaticojejunostomy. Closed
suction drains should always be placed.
Injuries to the head of the pancreas may require complex
operations associated with high mortality and morbidity.
In the presence of hemodynamic instability or major
associated injuries, or if the surgeon has no experience with
these injuries, the safest option is hemostasis and liberal
external drainage. Damage control with packing and
temporary abdominal closure may be necessary in cases
with difficult, persistent bleeding. Fig. 26.8(b). Completed end-to-end pancreaticojejunostomy.
226
In destructive injuries to the head of the pancreas or the Tips and pitfalls
duodenum, a pancreaticoduodenectomy may be necessary.
Pancreatic injuries without ductal involvement rarely cause
It should only be performed as a primary procedure in
significant problems and do not require an operation.
hemodynamically stable patients by an experienced
surgeon. In coagulopathic or physiologically compromised Distal pancreatectomy (to the left of the neck of the
pancreas) rarely results in permanent diabetes or
patients the surgeon should opt for damage control and a
pancreatic exocrine insufficiency.
two-stage procedure. At the initial operation, damage
control surgery should be performed to control the Mobilization and separation of the head of the pancreas
hemorrhage and any intestinal spillage. The definitive from the medial aspect of the duodenal loop results in
Whipple’s pancreaticoduodenectomy should be deferred duodenal ischemia and necrosis. A minimum of 1 cm of
for 24 to 48 hours after restoration of hemodynamic pancreatic tissue should be left behind in order to preserve
stability, and after correction of any coagulopathy and the pancreaticoduodenal vascular arcades.
hypothermia. The reconstruction, including In isolated injuries involving the head of the pancreas, if
pancreaticojejunostomy, choledochojejunostomy, and the integrity of the duct cannot be confirmed, pancreatic
gastroenterostomy, is similar to that in elective cases and drainage alone should be considered. Radical resections
will not be discussed in the current Atlas. should be avoided because of the high mortality and
Insertion of a jejunal feeding tube beyond the ligament of morbidity. The pancreatic duct should be evaluated
Treitz is recommended in cases undergoing postoperatively by means of MRCP or ERCP. In cases with
pancreaticoduodenectomy or complex duodenal repairs, in ductal injury, ERCP-placed stenting may be considered.
order to allow enteral nutrition in cases with postoperative During tunneling between the neck of the pancreas and the
anastomotic leaks. superior mesenteric vessels and portal vein, stay in the
midline, directly under the neck. This area is avascular.
227
Section 6 Abdomen
Urological trauma
Chapter
27 Charles Best and Stephen Varga
Surgical anatomy
Kidney
Both kidneys have similar muscular surroundings.
Posteriorly, the diaphragm covers the upper third of each
kidney. Medially, the lower two-thirds of the kidney lie
against the psoas muscle, and laterally, the quadratus
lumborum.
The right kidney borders the duodenum medially. Its lower Right gonadal vein
pole lies behind the hepatic flexure of the colon. Left gonadal vein
The left kidney is bordered superiorly by the tail of the
pancreas, the spleen superolaterally, and the splenic flexure
of the colon inferiorly.
Gerota’s fascia encloses the kidney and is an effective
barrier for containing blood or a urine leak.
The renal artery and vein travel from the aorta and IVC
just below the SMA at the level of the second lumbar
vertebra. The vein lies anterior to the artery. The renal
pelvis and ureter are located posterior to the vessels.
The right renal artery takes off from the aorta with a
downward slope under the IVC into the right kidney. The
left renal artery courses directly off the aorta into the left Fig. 27.1. Anatomy of the kidneys and ureters and their relationship with the
major vessels. Note the right renal artery coursing under the inferior vena cava.
kidney. Each renal artery branches into five segmental The ureters cross over the bifurcation of the common iliac arteries (circle).
arteries as it approaches the kidney.
The right renal vein is typically 2–4 cm in length, does not
receive any branches and enters into the lateral edge of the
IVC. Ligation of the vein causes hemorrhagic infarction of
the kidney because of the lack of collaterals.
The left renal vein is typically 6–10 cm in length, passes Ureter
posterior to the SMA and anterior to the aorta. The left The ureter courses posterior to the renal artery and travels
renal vein receives branches from the left adrenal vein along the anterior edge of the psoas muscle.
superiorly, lumbar veins posteriorly, and the left gonadal The gonadal vessels cross anterior to the ureter.
vein inferiorly. This allows for ligation of the left renal vein The ureter crosses over the bifurcation of the common iliac
proximal to the kidney close to the IVC. artery.
228
Chapter 27. Urological trauma
Bladder In unstable patients or in those undergoing a

planned nephrectomy, a direct approach through
The superior surface of the bladder is covered by
Gerota’s fascia without prior vascular control is faster
peritoneum. Posteriorly, the peritoneum passes to the level
and preferable.
of the seminal vesicles (in males) and meets the peritoneum
on the anterior rectum.
The bladder neck rests approximately 3–4 cm behind the Proximal renal vascular control
midpoint of the symphysis pubis. Proximal control of both the left and right renal vessels can
be obtained directly through a single incision of the
Kidney injuries retroperitoneum over the abdominal aorta.
The transverse colon is retracted anteriorly and
General principles superiorly, towards the patient’s chest. The small
In hemodynamically stable patients the vast majority of intestine is wrapped in a moist towel and retracted
blunt and a significant proportion of penetrating renal superiorly and to the right to expose the ligament of
injuries can be managed non-operatively. Gerota’s fascia Treitz, the root of the mesentery, and the underlying
effectively contains bleeding and urine leaks. CT scan great vessels.
evaluation is important in assessing the severity and An incision is made in the posterior peritoneum, over
location of the injury. The addition of a delayed CT scan the aorta, just above the inferior mesenteric vein. The
allows for the evaluation of the collecting system and dissection continues superiorly along the aorta until the
proximal ureter. left renal vein is identified, crossing over anteriorly.
If no pre-operative imaging is available and the patient is A vessel loop is placed around the vein for retraction.
undergoing exploratory laparotomy, it is important to Once the left renal vein is mobilized and retracted,
assess by palpation the presence and size of the dissect out the left renal artery, which is located
contralateral kidney. posterior to the renal vein.
Intraoperatively, in a hemodynamically stable patient, in
the absence of active bleeding or expanding hematoma or
injury to the hilar vessels, Gerota’s fascia should not be HEAD
opened as it increases the probability of nephrectomy.
Nephrectomy should be reserved for life-threatening
hemorrhage or renal injuries that are beyond repair: Left renal artery
approximately 10% of renal injuries. Uncontrolled
hemorrhage is the most common reason for unplanned
nephrectomy in a trauma setting. Small bowel
If time allows, proximal vascular pedicle control should be
considered before kidney exploration, in order to reduce
the need for nephrectomy.
Left renal vein

Patient positioning
The patient is placed in the standard trauma laparotomy
position supine with both arms abducted at 90 degrees to Aorta
allow access to the extremities.
Incision Right
Standard midline trauma laparotomy incision. Inferior mesenteric vein
A Bookwalter or other fixed abdominal retractor facilitates
the exposure. Feet
Fig. 27.2. Dissection in the posterior peritoneum lateral to the aorta and just
Kidney exposure above the inferior mesenteric vein, and continuing superiorly along the aorta,
will identify the left renal vein crossing the aorta anteriorly. The left renal artery
Proximal vascular control, before opening the Gerota’s is located posterior to the vein.
fascia, may be considered in stable patients if a kidney-
preserving operation is planned. This approach increases
the chances of kidney salvage.
229
Section 6: Abdomen
After vascular control has been achieved, a medial visceral (b)

rotation is performed by mobilizing the left colon along the
white line of Toldt and reflecting the colon medially. The
kidney is then exposed by making an anterior vertical
incision in Gerota’s fascia.
Head
(a)
Renal artery
HEAD
Renal vein
Spleen Left kidney
Left
colon Ureter
Left kidney
Feet
Fig. 27.3(b). Exposure of the left kidney and the hilum after medial rotation of
the left colon (artery in red, vein in blue and ureter in yellow loop).
White line (c)

of Toldt
Feet Le
ft k
idn
ey
Left renal vein
Fig. 27.3(a). Incision of the white line of Toldt, and mobilization and medial
rotation of the left colon, exposes the left kidney.
AORTA
IVC IMV
The right renal vessels can be exposed through the same

posterior peritoneal incision, described above. The right
renal artery originates from the right side of the aorta and
Fig. 27.3(c). Exposure of the left kidney and the hilum after medial rotation of
courses under the inferior vena cava and behind the the left colon. Note the left renal vein crossing over the aorta. (IVC: inferior vena
renal vein. cava, IMV: inferior mesenteric vein.)
230
As described above, the left renal vein is mobilized and (b)

retracted as it crosses over the aorta. The right renal artery,
which is located posterior to the vein and to the right of the HEAD
aorta, is identified.
Finally, identify the right renal vein traveling to the inferior
vena cava and control with a vessel loop. Branch of
After vascular control has been achieved, perform a right renal artery
medial visceral rotation, mobilizing the right colon by Right
kidney Right renal vein
incising the white line of Toldt and reflecting it medially.
Explore the right kidney by making an anterior vertical Right renal
artery
incision in Gerota’s fascia. Completely expose the kidney,
mobilizing it and lifting it anteriorly into the wound. Psoas IVC
(a)
Right ureter
HEAD
Fig. 27.4(b). Exposure of the right kidney and the hilum after medial rotation
of the right colon. Note the renal vein anteriorly, the artery posteriorly and the
Right renal artery ureter inferiorly.
Renal injury repair

After opening Gerota’s fascia and exposing the kidney, the
extent of the injury is assessed. In cases with significant
bleeding from the parenchyma, the renal vessels are
clamped for bleeding control. Manual compression of the
bleeding parenchyma is often adequate for temporary
Left renal control of the hemorrhage. Any significant bleeders are
vein controlled by suture ligation or by electrocautery.
Aorta
Once hemorrhage is controlled, any devitalized tissue is
sharply excised. The collecting system is carefully examined
and any injury is repaired watertight with a 4–0 absorbable
suture.
Feet
Left renal vein
Fig. 27.4(a). Exposure of the right renal vessels through a midline

retroperitoneal dissection. The left renal vein is identified as it crosses over the
aorta and is retracted to expose the underlying right renal artery (red loop). LEFT KIDNEY
Direct kidney exposure without prior

vascular control
This is a common approach to the kidney and the preferred
approach in patients with hemodynamic instability or
unsalvageable renal injuries.
A medial visceral rotation is performed by mobilizing the
left or right colon, after incising the white line of Toldt.
Gerota’s fascia is opened with an anterior vertical incision
and the kidney is exposed and delivered anteriorly. Fig. 27.5. Repair of injury to the collecting system (circle), of the lower pole of
The blood supply and ureter can then be controlled. the left kidney, with 4–0 absorbable suture.
231
Section 6: Abdomen
If unsure of the presence of a collecting system injury or to (a)

check if the collecting system repair is watertight,
HEAD
methylene blue can be used to look for a leak. Place a
bulldog clamp on the proximal ureter and, using a 22-
gauge or smaller butterfly needle, directly inject 2 to 3 mL
methylene blue into the renal pelvis to look for further
leaks or injury. If identified, close the leaks or repair the
injury with figure-of-eight, 4–0 absorbable sutures.
HEAD Left kidney
Ureter Renal vein
Renal capsule
Left kidney
Needle in
ureter, above
clamp Renal injury
Fig. 27.7(a). Suturing of pledgets on intact renal capsule edges, for primary
repair of injury.
Fig. 27.6. Intraoperative evaluation of the integrity of the collecting system: First, attempt to dissect the capsule off the damaged
insertion of a 22-gauge needle into the proximal ureter, with bulldog clamp parenchyma for assistance with closure later.
applied distally, and injection of 2–3 mL of methylene blue into the renal pelvis.
Extravasation of the methylene blue (circle) confirms injury to the collective Perform a guillotine transection of the renal parenchyma
system. back to healthy bleeding tissue. Control small bleeding
vessels with figure-of-eight 4–0 absorbable sutures, and
close the collecting system in a watertight fashion with a
4–0 absorbable suture. Topical hemostatics may be placed
on the renal parenchyma to aid in hemostasis.
If possible, the renal capsule should be primarily closed, If the renal capsule has been preserved, close the capsule
without tension, using pledgets. over the raw surface of the kidney with a 3–0
If the defect in the capsule is large, an omental pedicle flap, polypropylene or vicryl suture with or without pledgets. If
fibrin sealant, or thrombin-soaked GelFoam bolsters can the capsule could not be preserved or if the injury is too
be used to fill the defect. The capsule should then be closed extensive to cover completely, the defect can be covered by
over the bolster or flap with pledgeted 4–0 polypropylene an omental flap or absorbable material such as GelFoam,
sutures. which can be sutured to the remaining renal capsule with
If other intra-abdominal injuries are present, an omental 3–0 polypropylene or vicryl sutures.
interposition flap should be placed over the renal injury to A retroperitoneal drain should be placed at the end of the
separate the kidney from the other injuries. operation.
A retroperitoneal drain should be placed at the end of the
operation.
Nephrectomy
If the injury to the kidney is too extensive for repair, a
nephrectomy is warranted. If the patient is unstable, and
Partial nephrectomy the kidney is the source of hemorrhage, likewise
Extensive damage to the upper or lower poles of the kidney nephrectomy is warranted. No preliminary vascular
requires partial nephrectomy rather than primary repair. isolation is needed. After medial visceral rotation, Gerota’s
232
(b) (a)
Transverse colon
Left kidney
Head
Left kidney
Omental flap
Right Left ureter
Fig. 27.8(a). Omental pedicle flap may be used to fill in large parenchymal
defects, not amenable to primary repair. The flap is anchored to the capsule
with sutures (red circles).
Feet
(b)
HEAD
Fig. 27.7(b). Definitive, tension-free, repair of left kidney injury using pledgets.
fascia is opened and the kidney is delivered anteriorly. Left kidney

Digital compression of the hilum is applied to control the
bleeding. Ligate the artery and the vein, near the kidney
hilum, with 0 silk ties. The ureter should be identified and
ligated with a 2–0 silk tie.
Pledgets
Tips and pitfalls

Failure to identify a collecting system injury or failure to
Bolster
perform a watertight closure of the collecting system may
result in a urinoma postoperatively.
Parenchymal tissue typically will not hold a suture, so
capsular tissue approximation should be used.
During debridement or partial nephrectomy, preserve as
much renal capsule as possible for repair or cover of the
raw surface.
Attempting to close the capsule primarily over a large Fig. 27.8(b). Hemostatic bolster used to repair a large defect that cannot be
defect will cause tearing of the capsule and further bleeding closed primarily without tension with closure of the capsule over the bolster.
233
Section 6: Abdomen
(a) (c)
HEAD
LEFT KIDNEY
Left ureter Fig. 27.9(c). Partial lower pole nephrectomy with preservation of the capsule:
the capsule can close over the raw surface of the kidney.
or injury. Omentum or GelFoam can be utilized to cover

Lower pole the bare area.
Postoperative urine leak increases the risk of breakdown of
any adjacent hollow viscus or vascular anastomosis or
repair. Separate the renal repair from other organ injuries
with omentum or other available tissue. Routine closed
suction drains should be placed.
Fig. 27.9(a). Extensive damage to the lower poles of the kidney is best Postoperative care
managed with partial nephrectomy. Patients who have undergone kidney repair should be
followed with periodic urinalysis, blood pressure
monitoring, and CT scan with intravenous contrast, in
(b) order to rule out early or late complications such as a
urinoma, kidney infarct, false aneurysm, arteriovenous
fistula, or secondary hypertension.
HEAD Urinomas are the most common complication, and they
can be managed by endoscopic stenting with or without
percutaneous drainage.
Bolster
LEFT KIDNEY False aneurysms, or arteriovenous fistulas can be managed
by angioembolization.
Hypertension can be managed medically, but if medical
management fails, a delayed nephrectomy may be
indicated.
Ureter injury
General principles
Early recognition and treatment of ureteral injuries is
Feet important because failure to recognize these injuries can
result in loss of renal function, sepsis, or death.
Pledgets
In patients undergoing laparotomy for penetrating trauma,
all retroperitoneal hematomas should be explored and the
Fig. 27.9(b). Partial lower pole nephrectomy with the raw surface covered
with absorbable materials such as GelFoam, which can be sutured to the
ureter examined for any injury. The ureter can be inspected
remaining renal capsule. with or without the use of intravenous or intraureteral dye.
234
The ureter can be divided into three separate anatomical The injured part of the ureter should be debrided to viable
areas when considering repair, including the proximal, mid tissue.
and distal ureter. The proximal ureter is the segment above Take care not to injure or devitalize the ureter.
the iliac bifurcation. The mid ureter is the segment between The ureter is mobilized to allow the proximal and distal
the iliac bifurcation and the deep pelvis. The distal ureter is ends to come together without tension.
defined as the segment of ureter below the internal iliac Spatulate the ends of the ureter to prevent stenosis at the
artery. Each of these anatomic areas requires a different suture line.
type of repair. Place an indwelling double-J-type stent into the proximal
The type of ureteral repair depends on the level of the and distal ends of the ureter.
injury, the amount of ureteral loss, and the condition of the Perform a tension-free, mucosa-to-mucosa anastomosis
patient. The general principles for all ureteral repairs are using an interrupted 4–0 or 5–0 absorbable suture.
debridement to healthy tissue with a tension-free Place a retroperitoneal drain near the repair site. In the case
watertight repair over a stent. of bowel or pancreatic injuries in addition to ureteral
In severe trauma the patient may not be stable enough to injuries, every attempt should be made to isolate the
undergo extensive ureteral repair during the initial ureteral repair from the other injuries by covering it with
operation. In these cases a damage control procedure an omental flap or local tissue.
should be considered. If a ureteral transection is identified,
the proximal and distal ends of the ureter can be ligated
and tagged and left in place to be repaired semi-electively
after the patient has stabilized. Alternatively, an external Repair of the distal ureter
stent can be placed in the proximal ureter and brought out Distal ureter injuries usually occur in the setting of a pelvic
through the abdominal wall through a separate stab hematoma, making the dissection difficult. If an injury is
incision in the abdomen to allow for monitoring of urine identified, direct re-implantation of the distal ureter into
output during resuscitation. Immediate diversion is not the bladder is preferable if it can be performed tension-free.
necessary, as the affected kidney can tolerate complete This should be done in an anti-refluxing fashion if possible
obstruction for several days until a definitive repair can be over a stent.
performed. If repair will be significantly delayed for clinical Although anti-refluxing is not crucial in the adult patient,
reasons, a percutaneous nephrostomy tube should be an attempt should be made to perform an anti-refluxing
considered. tunnel with an extravesical reimplant if a psoas hitch is not
required. Once the ureter has been adequately mobilized, a
tunnel is created in the posterolateral dome, by dissecting
Repair of the proximal and mid ureter off the detrusor muscle, leaving small muscle flaps on
Explore the retroperitoneum by performing a medial either side. A hole can be made in the bladder mucosa at
visceral rotation, mobilizing the ipsilateral colon by the apex of this trough, and the spatulated ureteral end can
incising the white line of Toldt and reflecting it medially. be anastomosed over a stent with interrupted 4–0 vicryl
Identify the ureter and trace it proximally and distally to suture. The muscle flaps are then laid over the ureter in this
examine the extent of injury. trough, and secured with 3–0 vicryl absorbable suture.
Fig. 27.10. Ureter transection sharply debrided

to healthy tissue prior to anastomosis.
HEAD
Distal ureter
PSOAS
Feet Proximal ureter
235
Section 6: Abdomen
and obliquely toward the side of the injury. The lateral

peritoneal attachments are then divided as needed for
mobilization. The bladder body can then be displaced
towards the side of the injury and sutured to the psoas
muscle with a 2–0 non-absorbable suture. The distal ureter
can then be re-implanted into the bladder using a tunneled
anti-refluxing anastomosis with a stent. The bladder is then
closed in two layers with a 2–0 or a 3–0 absorbable suture.
If there are adjacent vascular or visceral repairs, every
attempt should be made to isolate the ureteral repair by
placing an omental pedicle flap over the repair to prevent
fistula formation.
Tissue sealant may be applied to the area of anastomosis.
Ureter Place drains after the repair.
Tips and pitfalls

Feet Avoid extensive dissection of the surrounding tissues
during mobilization of the ureter. The ureter receives its
blood supply from the surrounding tissues medially, and
extensive dissection may cause ischemia of the repair site
and either stricture or breakdown of the anastomosis.
Fig. 27.11. Spatulated end (circle) of the transected ureter.
Failure to use a double-J stent or to spatulate the ends of
the ureter when doing the primary repair increases the risk
of anastomotic stricture.
If the distal anastomosis cannot be performed tension-free, When performing re-implantation, ensure there is no acute
the bladder may be mobilized to the transected ureter to angulation of the ureter as it enters the bladder, as acute
perform a “psoas hitch.” The bladder is opened vertically angulation will prevent adequate drainage of the ureter.
Fig. 27.12. Placement of an indwelling double-J-

type stent into the proximal and distal ends of the
ureter.
Distal ureter
HEAD
Proximal ureter
Double-J-type stent
236
Fig. 27.13. Tension-free, mucosa-to-mucosa

anastomosis using interrupted 4–0 absorbable sutures
over double-J-type stent.
Distal ureter
HEAD
PSOAS
Proximal ureter
Double-J-type stent
Fig. 27.14. Omental flap covering ureteral

anastomosis.
Distal ureter
HEAD
Omental flap
Proximal ureter
Postoperative care retrograde pyelography to demonstrate a patent

Drains should be left in the retroperitoneum until the anastomosis without any evidence of urine leak. Ureteral
output is minimal. Internal stents should be removed patency should be reassessed again after 3 months with
endoscopically through the bladder 4–6 weeks excretory urography, or renal ultrasound to assess for
postinjury, followed by excretory urography or hydronephrosis.
237
Section 6: Abdomen
(a) (c)
HEAD
Proximal ureter
BLADDER PELVIS
BLADDER
Detrusor muscle flaps

Opening in bladder Detrusor muscle flaps
mucosa
Fig. 27.15(c). Closure of detrusor muscle flaps over the ureteral anastomosis
Fig. 27.15(a). Preparation of the bladder for distal ureter anastomosis. with 3–0 absorbable sutures.
A tunnel is made in the ipsilateral, posterolateral dome by dissecting off
the detrusor muscle, leaving small muscle flaps on either side to cover
anastomosis later. A hole is made in the bladder mucosa at the apex of
this trough.
Bladder injury
General principles
(b)
Injuries to the bladder are classified according to the location
of rupture. Intraperitoneal bladder rupture always requires
operative repair. Extraperitoneal ruptures can be managed
with urethral catheter drainage alone. Some bladder injuries
can be a combination of both intraperitoneal and
Spatulated proximal
extraperitoneal ruptures and should be fixed surgically.
ureter
HEAD Detrusor muscle flaps

Repair of bladder injury
BLADDER Intraperitoneal bladder ruptures almost always involve the
dome of the bladder. Inspect and palpate the bladder
through the laceration to verify that there are no other
injuries and that there is clear efflux from both ureteral
orifices. If necessary, the laceration can be extended, to
adequately visualize the inner surface of the bladder.
Double-J-type stent Debride any devitalized tissue.
If extraperitoneal lacerations are seen on examination,
close them from inside the bladder with a single layer of
interrupted 3–0 or 4–0 absorbable sutures.
Once inspection and repair of extraperitoneal lacerations is
complete, close the laceration in two layers using 2–0 or
Fig. 27.15(b). Spatulated proximal ureteral end is anastomosed to the
3–0 absorbable sutures.
bladder mucosa over a stent with interrupted 4–0 absorbable sutures. Place a drain near the repair.
238
Tips and pitfalls

PELVIS In penetrating injuries with no accountable second bladder
wound, always examine the bladder from the inside, in
order to avoid missed injuries.
Urethral catheter Test the closure by instilling the bladder with sterile
irrigation through the existing urethral catheter. Any
significant leaks may be oversewn with 3–0 absorbable
sutures in a figure-of-eight fashion. Tiny leaks will most
likely seal on their own. Tissue sealant may be applied.
Postoperative care
Intraperitoneal drains should be left in place until output
is minimal. The urethral catheter should be left in place
for 7 to 10 days. If there is any concern about bladder
healing, a cystogram can be performed to evaluate for urine
Opened bladder Head leakage from the repair. This should be considered for all
complex repairs, and for those involving the trigone of the
bladder.
Fig. 27.16. Intraperitoneal bladder rupture with laceration extended into an
anterior midline cystotomy to fully visualize the inside of the bladder.
PELVIS
BLADDER
Fig. 27.17. Intraperitoneal bladder laceration (circle) repaired in two layers

using 3–0 absorbable sutures.
239
Section 6 Abdomen
Abdominal aorta and visceral branches

Chapter
28 Pedro G. Teixeira and Vincent L. Rowe
Surgical anatomy Zone 2 Zone 1 Zone 2

For vascular trauma purposes, the abdomen is
conventionally divided into four retroperitoneal
anatomical areas.
Zone I. The midline retroperitoneum from the aortic
hiatus to the sacral promontory is broken into the
supramesocolic and inframesocolic areas. The
supramesocolic area contains the suprarenal aorta
and its major branches (celiac artery, superior
mesenteric artery, and renal arteries), the
supramesocolic segment of the inferior vena cava with
its major branches, and the superior mesenteric vein.
The inframesocolic area contains the infrarenal aorta
and the inferior vena cava.
Zone II (left and right). This is the paired right and left
region lateral to Zone 1 and contains the kidneys with
the renal vessels.
Zone III. The pelvic retroperitoneum, which contains
the iliac vessels.
Zone IV. This is the retrohepatic area containing
the retrohepatic inferior vena cava and the hepatic
veins.
The abdominal aorta originates between the two
crura of the diaphragm at the T12 to L1 level and bifurcates
into the common iliac arteries at the L4 to L5 level. The
external landmark for the bifurcation is the umbilicus. The
Zone 3
first branches are the phrenic arteries, which originate
from its anterolateral surface. Immediately below this
is the origin of the celiac trunk, and 1 to 2 cm below this
is the superior mesenteric artery. The renal arteries
originate 1 to 1.5 cm below the origin of the superior
mesenteric artery at the level of L2. Finally, the inferior
Fig. 28.1. Retroperitoneal vascular zones: Zone I includes the midline vessels
mesenteric artery originates 2 to 5 cm above the aortic from the aortic hiatus to the sacral promontory; Zone II the paracolic gutter and
bifurcation. the kidneys; Zone III the pelvic retroperitoneum.
240
Chapter 28. Abdominal aorta/visceral branches
Phrenic a Phrenic a
Celiac a
SMA L1
Celiac a
Renal a Superior mesenteric a
L2
Renal a
IMA
L4
Gonadal a
Iliac a
Inferior mesenteric a
Fig. 28.3. Anatomy of the major branches of the abdominal aorta. Note the
site of division (dashed line) of the left crux of the diaphragm, at the avascular 2
o’clock, for exposure of the lower thoracic aorta.
Fig. 28.2. Lateral view of the major visceral branches of the abdominal aorta.
Note the tight concentration of the supramesocolic vessels: celiac artery,
superior mesenteric artery (SMA), and renal vessels. artery, an arterial arcade with 12–18 intestinal
branches, the right colic artery, and the ileocolic artery.
Renal arteries. The right renal artery emerges at a
Celiac artery. The main trunk is 1 to 1.5 cm long and at slightly higher level and is longer than the left and
the upper border of the pancreas it separates into three courses under the inferior vena cava. Approximately
branches (the tripod of Haller), which includes the 30% of the population have more than one renal
common hepatic, left gastric, and splenic arteries. Due artery, usually an accessory artery supplying the
to the extensive fibrous, ganglionic, and lymphatic lower pole of the kidney. The renal vein lies in front
tissues which surround the trunk, surgical dissection in of the renal artery. The left renal vein is significantly
this area is difficult. longer than the right and courses in front of the
Superior mesenteric artery (SMA). The SMA originates aorta and drains the left gonadal vein inferiorly, the
from the anterior surface of the aorta, 1 cm to 2 cm left adrenal vein superiorly, and a lumbar vein
below the celiac artery, behind the pancreas, at the level posteriorly.
of L1. It then courses over the uncinate process of the Inferior mesenteric artery (IMA). The IMA provides
pancreas and the third part of the duodenum and enters blood supply to the left colon, sigmoid, and upper part
into the root of the mesentery. Branches include the of the rectum. It communicates with the SMA through
inferior pancreaticoduodenal artery, the middle colic the marginal artery of Drummond.
241
Section 6: Abdomen
General principles abdomen, and groin, in anticipation of a possible

thoracotomy or venous conduit harvesting.
Hemorrhage resulting from abdominal vascular injuries is
not amenable to temporary control by application of
external pressure. Immediate operative intervention is the Incision
cornerstone of survival.
Extended midline trauma laparotomy, from xiphoid to
Penetrating abdominal vascular injuries are usually pubic symphysis.
associated with hollow viscus injuries, which increase the
For proximal aortic control in cases with high
complexity of the operation and expose the vascular repairs supramesocolic bleeding or hematoma, a left anterolateral
to contamination from enteric contents. thoracotomy through the fifth intercostal space may be
In physiologically compromised patients, if the injured needed. The technical aspects are described in Chapter 4.
vessel cannot be ligated, temporary stenting with delayed
definitive reconstruction should be utilized.
Abdominal arterial and venous injuries occur with the Exposure
same incidence. The most commonly injured abdominal In penetrating trauma, upon entering the peritoneal cavity,
vessel is the inferior vena cava, followed by the aorta. the usual findings include free intraperitoneal bleeding or a
In suspected abdominal vascular injuries, where the IVC or retroperitoneal hematoma or a combination of the two. In
iliac veins may be injured, the femoral veins should not be blunt trauma the most likely finding is a retroperitoneal
used for venous access. hematoma, which may or may not be expanding or
During induction of anesthesia in patients with severe pulsatile.
intra-abdominal bleeding, there is a high risk of rapid The management of retroperitoneal hematomas depends
hemodynamic decompensation or even of cardiac arrest. on the mechanism of injury.
The patient should be prepared and draped and the surgical
As a general rule, almost all hematomas due to
team ready to enter prior to the induction of anesthesia.
penetrating trauma should be explored, irrespective of
The value of systemic heparin is limited because of the size. Often, underneath a small hematoma there is a
trauma-induced coagulopathy. Local heparinized saline vascular or hollow viscus perforation. The only
(5000 units in 100 mL saline) however, should be used exception to this recommendation is a stable and non-
liberally. expanding retrohepatic Zone IV hematoma. Surgical
About 15% of patients with intra-abdominal vascular exploration of the retrohepatic vena cava or the hepatic
injuries are in cardiac arrest on arrival. These patients may veins is challenging and may cause harm.
benefit from a left anterolateral resuscitative thoracotomy
Retroperitoneal hematomas due to blunt trauma rarely
and cross-clamping of the aorta above the diaphragm (see require exploration because of the very low incidence of
Chapter 4). underlying vascular or hollow viscus injuries requiring
surgical repair. The only indications for exploration of
Special surgical instruments hematomas due to blunt trauma include a
paraduodenal hematoma, large expanding or leaking
In addition to a standard trauma laparotomy instrument
hematoma, and a hematoma in the region of the
tray, vascular clamps with multiple lengths and angulations
superior mesenteric artery associated with
must be available.
® ischemic bowel.
A self-retaining retractor, such as Omni-Tract or
®
Bookwalter can aid in providing exposure. Exploration of Zone I
A U-shaped aortic compression device should be available
for temporary aortic control below the diaphragm. If this is Supraceliac aortic control
not available, a sponge stick or manual pressure can Proximal control and direct compression or
be used. cross-clamping of the distal thoracic and proximal
Surgical head light and magnifying loupes should be abdominal aorta can be achieved below the
available. diaphragm, through a midline laparotomy, in
A thoracotomy instrument tray with a Finochietto most cases.
retractor should be available, should a left anterolateral At the aortic hiatus of the diaphragm, the aorta is
thoracotomy be necessary for aortic cross-clamping. surrounded by dense connective, nervous, and lymphatic
tissue, which makes the exposure difficult. However, more
proximally, at the distal thoracic aorta level, the vessel is
Positioning free from this dense periaortic tissue and can be more
Supine, with upper extremities abducted to 90 degrees. easily exposed. This segment is accessible through the
Skin antiseptic preparation should include the chest, esophageal hiatus.
242
The first step for this approach is to mobilize the left lobe Using blunt digital dissection, the distal thoracic
of the liver. The round ligament of the liver is divided aorta is isolated and a DeBakey or Cooley aortic
between clamps and ligated, and the falciform ligament aneurysm clamp is applied. After adequately
is divided with electrocautery. The left triangular positioning, the clamp should be stabilized using an
ligament of the liver is then divided. This maneuver is umbilical tape or a vessel loop secured to the surgical
facilitated by positioning the surgeon’s right hand drapes. Blind application of a clamp in this area is
behind the left lobe of the liver, using the right thumb ineffective and may cause iatrogenic injury.
to retract the liver caudad. The left triangular ligament An alternative strategy for rapid temporary supraceliac
is then divided with electrocautery over the surgeon’s aortic control is the utilization of a U-shaped aortic
right index finger and the left lateral segment of the compression device. This handheld device is positioned
liver is folded medially, exposing the esophageal over the supraceliac aorta through the lesser sac. Applying
hiatus. constant anteroposterior pressure, the device compresses
While the left lobe of the liver is folded medially, the the aorta against the spine until definitive control of the
stomach is retracted to the patient’s left and downward bleeding is achieved. The advantage of this technique is the
to expose the gastrohepatic ligament. The ligament is minimal dissection needed for application of the device,
then opened and the crux of the diaphragm is exposed. but a second assistant is required to hold pressure while
The esophagus is circumferentially dissected at the definitive bleeding control is pursued.
gastroesophageal junction and encircled with a Penrose In cases with a high supramesocolic hematoma where
drain for traction. infradiaphragmatic exposure of the aorta is difficult or not
The left diaphragmatic crux is then divided at the possible, a left thoracotomy may be necessary for aortic
avascular 2 o’clock position. control.
(a) Fig. 28.4(a). Mobilization of the left lateral

segment of the liver to expose the area of the
esophageal hiatus. The falciform ligament has been
divided and the surgeon’s right index finger is
positioned posteriorly to the left triangular
ligament of the liver.
Triangular
ligament
HEAD Left lateral

segment
Falciform
ligament
243
Section 6: Abdomen
(b) Fig. 28.4(b). Division of the left triangular

ligament of the liver with electrocautery. This
maneuver allows the left lateral segment to be
HEAD retracted medially to expose the area of the
gastroesophageal junction.
Triangular
ligament
Left lateral
segment
(c) Fig. 28.4(c). The left lateral segment of the liver

has been retracted medially, exposing the
esophageal hiatus.
Spleen
Esophageal
Triangular
hiatus
HEAD ligament
Left lateral
segment
244
(a) Fig. 28.5(a). The stomach is retracted caudad

and the gastrohepatic ligament is divided.
Gastro-hepatic
ligament
Esophagus
Lesser curve
Stomach
(b) Fig. 28.5(b). After the esophagus is

circumferentially dissected at the gastroesophageal
junction, a Penrose drain is positioned around it for
traction. Note the use of Allis clamps to retract the
diaphragmatic crus fibers.
Esophagus
Left lateral
segment
Stomach
245
Section 6: Abdomen
(a) Fig. 28.6(a). With the esophagus retracted

downwards, a Peon clamp is advanced into the
esophageal hiatus of the diaphragm to facilitate
the division of the muscle fibers.
Diaphragmatic
crus
Esophagus
(b) Fig. 28.6(b). The right diaphragmatic crus is

divided at the 2 o’clock position.
Diaphragmatic
crus divided
Esophagus
246
(a) Fig. 28.7(a). The distal thoracic aorta has been

identified and isolated. Note how, at this level, the
aorta is free from surrounding connective, nervous,
and lymphatic tissue.
Esophagus
Aorta
(b) Fig. 28.7(b). A vascular clamp is applied to the

aorta. Note the esophagus retracted laterally and
protected from inadvertent injury with the
application of the clamp.
Liver
Esophagus
Stomach
Aorta
247
Section 6: Abdomen
(c) Fig. 28.7(c). Aortic control achieved by vascular

clamp successfully applied to the distal
thoracic aorta.
Liver
Esophagus
Stomach
Clamped aorta
Fig. 28.8. Aortic cava), the difficult exposure of many of these vessels, and
compression device the difficult proximal control of the
applied on the
supraceliac aorta through
infradiaphragmatic aorta.
the lesser sac. The aorta is The supramesocolic aorta with the origins of its major
compressed against visceral branches is best exposed by mobilization and
the spine.
medial rotation of the viscera, with or without mobilization
of the left kidney.
The first step of this approach is the division of the
peritoneal reflection lateral to the left colon (white line
of Toldt) and dissection of the left colon from the
lateral abdominal wall. This retroperitoneal plane is
developed anteriorly to the Gerota’s fascia if the
intention is to leave the left kidney in place.
The retroperitoneal dissection is continued cephalad
and the spleen is completely mobilized after division of
the splenophrenic ligament. Avoid excessive traction to
the splenic flexure of the colon or the spleen in order to
prevent inadvertent avulsion of the splenic capsule and
bleeding. The spleen, fundus of the stomach, pancreas,
colon, and small bowel are then rotated en-bloc
medially, exposing the aortic hiatus and origins of the
celiac axis, superior mesenteric artery, and left renal
artery.
Exposure of the aorta directly under the left renal vein
may be difficult. In this case, there are three possible
Exposure of the supramesocolic aorta options: (1) include the left kidney in the visceral
rotation, (2) mobilize the left renal vein, often after
and visceral branches ligation and division of its three tributaries (left
Zone I supramesocolic bleeding or hematomas are the gonadal vein, left adrenal vein, and ascending lumbar
most difficult to approach because of the dense vein), (3) division of the left renal vein. In this case the
concentration of major vessels (aorta, celiac artery, tributaries must be preserved and the left renal vein
superior mesenteric artery, renal vessels, inferior vena ligated and divided as close to the inferior vena
248
(a) Fig. 28.9(a). Left visceral rotation: traction of the

descending colon exposes the left peritoneal
reflection and the white line of Toldt is identified.
Line of
Toldt
HEAD
Left colon
(b) Fig. 28.9(b). The white line of Toldt being

divided with cautery and the left colon is mobilized
away from the lateral abdominal wall.
Left lateral abdominal wall
Line of Toldt,
division
Left colon
cava as possible in order to maintain venous outflow iatrogenic injury to the spleen and the tail of
from the left kidney. the pancreas.
The left visceral rotation provides good exposure to the Following medial visceral rotation, the exposure of the
supramesocolic aorta and its major branches. However, abdominal aorta is carried out by division of the tissues
it is associated with a significant risk of overlying its anterolateral surface.
249
Section 6: Abdomen
Fig. 28.10. After division of the white line of

Toldt, the plane between the left mesocolon and
the left kidney in entered and the left colon
mobilized medially. Note that the kidney was left at
its original position.
Left kidney
(a) Fig. 28.11(a). Medial visceral rotation has been

performed after division of the splenorenal and
HEAD splenophrenic ligaments. The pancreas and the
spleen have been rotated medially en bloc. The
posterior surface of the pancreas and its
anatomical relationship with the spleen is
Stomach
depicted. The left kidney remains at its original
position in the retroperitoneal area. Note the left
renal vein crossing anteriorly over the aorta.
Esophagus
Spleen
Pancreas
Left kidney
Left renal
vein
Left colon
250
(b) Fig. 28.11(b). Anatomy and visceral branches of

the abdominal aorta.
Stomach Esophagus
Left kidney
Left renal
artery
Left renal vein
IMA
SMA
Infrarenal
Aortic
aorta
bifurcation
Exposure of the inframesocolic aorta Celiac artery

The inframesocolic abdominal aorta can be exposed The celiac artery and its three proximal branches
directly by retracting the transverse colon cephalad and can be approached directly through the lesser sac.
displacing the small bowel to the right. The peritoneum Alternatively, exposure may be achieved through
over the aorta is then incised and the aorta is exposed. the previously described left medial visceral rotation.
An alternative approach is medial rotation of the The rotation need not include the left kidney.
left colon. It is rare that the celiac artery needs complex
Exploration of Zone II reconstruction. Ligation should be performed in all cases
Zone II is explored by mobilization and medial rotation of requiring anything more than simple arteriorrhaphy.
the right colon, the duodenum, and the head of the Ligation is unlikely to result in ischemic sequelae to the
pancreas on the right side or the left colon on the left side. stomach, liver, or spleen, because of the rich collateral
The source of bleeding in Zone II is usually the kidney and circulation. The left gastric and splenic arteries may also be
the renal vessels. ligated. The common hepatic artery is the largest of the
celiac artery branches and can be repaired with lateral
arteriorrhaphy, end-to-end anastomosis or venous graft
Exploration of Zone III interposition. However, ligation of the artery proximal to
The source of Zone III bleeding is usually the iliac vessels in the origin of the gastroduodenal artery, is often well
penetrating injury and the pelvic soft tissue and venous tolerated because of collateral blood supply. Transient
plexus in blunt injury. This area is explored by incising elevation of liver enzymes lasting for a few days is
the paracolic peritoneum and medial rotation of the common, but rarely has any clinical significance. However,
right or left colon. An alternative approach is by direct in some cases, especially in the presence of prolonged
dissection of the peritoneum over the vessels hypotension or associated liver injuries, segmental necrosis
(see Chapter 29). may be seen.
251
Section 6: Abdomen
Fig. 28.12. Anatomy of the celiac artery and its

three proximal branches. Note that the arcuate
ligament and the celiac ganglion have been
divided, exposing the anterior surface of the
supraceliac aorta. The celiac artery trunk is noted as
HEAD it branches into left gastric, splenic, and common
hepatic arteries.
Aorta
Celiac artery trunk
Left gastric artery

Splenic artery
Common hepatic
Pancreas
artery
Stomach
Superior mesenteric artery

Anatomically, the SMA is divided into four zones: Zone I, Portal vein
from the aortic origin to the inferior pancreaticoduodenal
branch; Zone II, from the inferior pancreaticoduodenal
artery to the middle colic artery; Zone III, distal to middle
colic artery; and Zone IV, the segmental intestinal
branches.
An alternative anatomical classification system uses only
two zones, the short retropancreatic segment and the
segment below the body of the pancreas, where it courses
over the uncinate process of the pancreas and the third part
of the duodenum.
SMA
Exposure of the SMA differs according to the site of the
injury.
Exposure of the retropancreatic SMA can be achieved
SMV
by medial visceral rotation, as described above. The
kidney does not need to be included in the rotation, Fig. 28.13. In cases with severe bleeding where immediate exposure of
the retropancreatic SMA is critical, stapled division (GIA stapler) of the neck
unless there is a suspicion of injury to the posterior wall of the pancreas provides fast and direct exposure of the SMA and the
of the aorta. portal vein.
252
Fig. 28.14. After left visceral rotation maneuver,

the retropancreatic SMA segment is exposed.
Left kidney
SMA, zone 1
Left renal vein
Infrarenal aorta
IMA
Pancreas
Common iliac
arteries
In cases with severe bleeding where immediate Reconstruction of the very proximal SMA is usually
exposure of the retropancreatic SMA is critical, performed with an autologous venous or synthetic
stapled division of the neck of the pancreas graft, between the distal stump of the SMA and the
provides fast and direct exposure of the SMA and the anterior surface of the aorta. For more distal injuries,
portal vein. an interposition venous graft between the transected
Exposure of the infrapancreatic SMA can be achieved ends of the vessel is usually required.
by cephalad retraction of the inferior border of the For patients in critical condition with severe hypothermia,
pancreas and direct dissection of the vessel. For more acidosis, and coagulopathy, a damage control procedure
distal injuries, exposure can be achieved with dissection with temporary endoluminal shunting should be
through the root of the small bowel mesentery, to the considered. This is preferable to ligation. Definitive
right of the ligament of Treitz. reconstruction is performed at a later stage after
In contrast to the celiac artery, ligation of the SMA results resuscitation and correction of the physiologic parameters
in variable degrees of ischemia according to the zone of the patient. The technique of temporary endoluminal
involved. Ligation at Zones I and II leads to extensive shunt placement is described in other chapters.
ischemia to the entire small bowel and right colon. Ligation of the SMA below the middle colic artery is
Ligation at Zones III and IV results in segmental small usually associated with a moderate risk of ischemia of
bowel ischemia. Unless irreversible bowel ischemia is the bowel. However, ligation of the proximal SMA
present at laparotomy, ligation of the SMA, especially in results in ischemic necrosis involving the small bowel
Zones I and II, should generally be avoided, if possible. and the right colon. The first 10 to 20 cm of the
Primary repair of the SMA may be possible in selected jejunum may survive via collaterals from the superior
cases of sharp transection of the vessel, usually inflicted by pancreaticoduodenal artery. Ligation of the SMA
knife wounds. The repair can be performed with 6–0 proximal to the origin of the inferior
vascular sutures. pancreaticoduodenal artery may preserve critical
In the presence of even limited tissue loss, an end-to-end collateral circulation to the proximal jejunum and is
anastomosis is rarely possible, because mobilization of the preferable to a more distal ligation. Ligation of the
SMA is restricted due to the surrounding dense proximal SMA should be performed only in the
neuroganglionic tissue and its multiple branches. presence of necrotic bowel. Ligation should be avoided
The management of complex SMA injuries not amenable in all other circumstances because of the catastrophic
to simple arteriorrhaphy should be determined by consequences of short bowel syndrome.
the condition of the patient, the site of the injury, and In the presence of an associated pancreatic injury the
the experience of the surgeon. The surgical options vascular anastomosis should be performed away from
for these patients include reconstruction with an the pancreas, if possible. The anastomosis should be
interposition graft, ligation, or damage control with protected with the use of omentum and surrounding
temporary shunting. soft tissues.
253
Section 6: Abdomen
Postoperatively, the patient should be monitored closely

for any signs of bowel ischemia (lactic acid, leukocytosis,
physiological deterioration). In the presence of any of
these signs, a second look laparotomy should be
performed to rule out bowel ischemia. If in doubt,
the abdomen should be left open during the original
operation.
Renal artery Right renal a

The left renal artery is more likely to sustain blunt trauma
than the right renal artery. The right renal artery is better
protected from deceleration injuries because of its course
underneath the IVC. Right renal v
The management of renovascular injuries depends on the
mechanism of injury, the ischemia time, the general
condition of the patient, and the presence of a contralateral Right kidney
normal kidney. IVC
Penetrating trauma always requires emergency
operative intervention because of severe bleeding. Right ureter
Blunt trauma to the renal artery often results in
thrombosis without bleeding. These cases may be
managed non-operatively or with endovascular
stenting. In cases with avulsion of the artery there is
severe bleeding and an emergency operation is
required.
In emergency operations for bleeding, a nephrectomy is
usually the procedure of choice.
Ligation of the right renal vein results in hemorrhagic
infarction of the kidney and should always be followed
by nephrectomy. However, ligation of the left renal vein
near the IVC without nephrectomy may be possible Fig. 28.15. After right medial rotation, the right renal hilum is identified.
The IVC is exposed. Note the position of the right renal artery, posterior to the
because of collateral venous drainage through the left right renal vein and to the IVC. The right ureter is demonstrated posterior to
gonadal, adrenal, and lumbar veins. the hilar vessels.
Exposure of the renal vessels.
The left kidney and renal vessels may be exposed An alternative approach to the exposure and
quickly by mobilization and by medial rotation of the proximal control of the renal arteries is through a
left colon. On the right side, mobilization of the right midline retroperitoneal exploration. The transverse
colon combined with a Kocher maneuver provides colon is retracted anteriorly and cephalad, placing the
excellent visualization of the renal system. Bleeding transverse mesocolon under tension. The ligament of
control is then achieved by digital compression or Treitz is divided and the duodenum is retracted caudad
application of a vascular clamp on the renal hilum. and to the right. The left renal vein is identified and
This is the most commonly used approach in trauma mobilized as needed to expose the origins of bilateral
surgery. renal arteries.
254
(a) (b)
Transverse colon
Left renal
artery
SMA
Transverse
mesocolon
Left renal
Middle colic Treitz vein
vessels
Proximal IVC
jejunum Infrarenal
aorta
Duodenum
Fig. 28.16(a). Transverse colon is retracted anteriorly and cephalad, placing Fig. 28.16(b). Midline retroperitoneal exploration after the ligament of
the transverse mesocolon under tension, exposing the fourth portion of the Treitz had been divided and the duodenum retracted caudad and to the right.
duodenum and the ligament of Treitz. Note the left renal vein crossing over anteriorly to the aorta. Mobilization of
the left renal vein provides access to the origin of bilateral renal arteries.
(c)
Left renal
SMA artery
Right renal
artery
Left renal
Infrarenal vein
aorta
Duodenum
Fig. 28.16(c). Through a midline retroperitoneal exploration, the left renal

vein has been retracted caudad and the origin of both renal arteries is noted.
Note the close proximity between the origins of the SMA and the renal arteries.
255
Section 6: Abdomen
Inferior mesenteric artery avoid inadvertent injury during application of the

Injury to the inferior mesenteric artery is managed by vascular clamp.
ligation. Division of the left crux of the diaphragm for exposure of
the distal thoracic aorta should be performed at 2 o’clock,
which is an avascular plane.
Tips and pitfalls During left medial visceral rotation, complete division of
In patients with suspected abdominal vascular injuries the splenic attachments to the diaphragm and careful
where the IVC or iliac veins may be injured, the femoral mobilization of the spleen decreases the chance of capsular
veins should not be used for venous access. avulsion and bleeding.
In a young trauma patient, a small and constricted aorta The descending lumbar vein is at risk of injury during
may be difficult to identify within a large retroperitoneal mobilization of the left kidney to expose the lateral wall of
hematoma. Likewise, the choice of conduit size for the aorta. It should be identified, ligated, and divided to
reconstruction acutely should take this vasoconstriction avoid laceration and unnecessary additional blood loss.
into account. In order to obtain increased exposure to the peri-renal
During control of the aorta at the hiatus, the aorta and renal arteries, the inferior mesenteric vein may
esophagus should be carefully retracted laterally to need to be ligated.
256
Section 6 Abdomen
Iliac injuries
Chapter
29 Demetrios Demetriades and Kelly Vogt
Anatomy of the iliac vessels

The abdominal aorta bifurcates into the two common
iliac arteries at the level of the fourth to the fifth lumbar
vertebrae (surface landmark is the umbilicus). The
Spermatic vessels
common iliac arteries are about 5–7 cm in length.
Common iliac v.
At the level of the sacroiliac joint, the common iliac arteries
Ureter
bifurcate to the external and the internal iliac arteries. External iliac a.
The external iliac artery runs along the medial border of External iliac v
the psoas muscle and goes underneath the inguinal
ligament to become the common femoral artery. It gives
two major branches: the inferior epigastric artery, just
above the inguinal ligament; and the deep iliac circumflex Iliac ligament
artery which arises from the lateral aspect of the external
iliac artery, opposite the inferior epigastric artery.
Fig. 29.1. Schematic anatomy of the iliac arteries, veins, and ureter crossing
The internal iliac artery is a short and thick vessel, about over the common iliac bifurcation. The left external iliac vein runs medial to the
3–4 cm in length. It divides into the anterior and posterior artery along its entire length. The right external iliac vein, above the inguinal
branches at the sciatic foramen. These branches provide ligament is medial to the artery and, as it courses proximally, it moves to the
right, posterior to the artery.
blood supply to the pelvic viscera, perineum, pelvic wall,
and the buttocks.
The ureter crosses over the bifurcation of the common
iliac artery. General principles
The common iliac veins lie mostly medial and posterior to For effective iliac vascular control, the internal iliac artery
the common iliac arteries. They join to form the inferior should always be included, because bleeding may persist
vena cava at the level of the fifth lumbar vertebrae, despite proximal and distal clamping of the vessels.
posterior to the right common iliac artery. Control of any enteric injuries and removal of enteric
The left external iliac vein runs medial to the artery along spillage should be done before definitive vascular
its entire length. The right external iliac vein above the reconstruction.
inguinal ligament is medial to the artery and, as it The presence of enteric contamination is not a
courses proximally, it moves to the right, posterior to contraindication for the use of synthetic grafts and there is
the artery. no need for routine extraanatomical bypass procedures.
257
Section 6: Abdomen
Copious irrigation and washout of the peritoneal cavity

before arterial reconstruction and tissue coverage with
Operative technique
adjacent peritoneum or omentum reduces the risk of graft The usual operative finding in iliac vascular injuries
is severe intraperitoneal bleeding or a large
infection.
retroperitoneal hematoma, or a combination of
Extra-anatomical bypass procedures are rarely indicated at
the two.
the acute stage, because of the critical condition of the
patient. They should be considered only in patients with Although proximal and distal control is desirable, in
the presence of severe bleeding direct entry into the
graft infection.
hematoma with exposure and compression control is
Ligation of the common or external iliac arteries should
often faster and more effective. Although exposure of
never be done because of the high incidence of limb loss
the vessels may be achieved through a peritoneal incision
and systemic complications. In patients in extremis a
over the distal aorta and the iliac vessels, a medial
damage control procedure with a temporary shunt should
rotation of the cecum and ascending colon on the right
be considered.
or the sigmoid and descending colon on the left, provide
The internal iliac artery can be ligated with impunity. a better exposure of the vessels and the ureters. The
Ligation of the common or external iliac veins is usually small bowel is rotated cephalad and to the opposite side
tolerated well. In most patients there is transient leg edema, of the vascular injury and held in place with warm, wet
which resolves with elevation and elastic stockings. In rare sponges. The paracolic peritoneal reflexion is incised
cases there is development of extremity compartment and the cecum or sigmoid is mobilized medially. The
syndrome requiring fasciotomy. bleeding is controlled by direct pressure, and proximal
Following arterial or venous injuries, the patient should and distal control is achieved with vascular clamps or
always be monitored for extremity compartment vessel loops.
syndrome. The combination of arterial and venous injuries
is associated with a high risk of compartment syndrome,
and liberal fasciotomy should be considered. (a)
Venous repairs producing more than 50% narrowing are
associated with a high incidence of pulmonary embolism.
In these cases consider ligation or a caval filter.
Special surgical instruments Aorta

The surgeon should have available a complete vascular
tray, along with a laparotomy tray. Right CIA
If possible, operations should be performed in a suite with Left CIA
angiographic capabilities.
Positioning
The patient should be supine on the operating table,
prepped to include access to the lower extremities.
Incisions
The majority of injuries can be adequately managed using
an extended midline laparotomy incision.
If the exposure of the distal iliac vessels is difficult, usually
due to a narrow pelvis, extension of the midline incision by
adding a transverse lower abdominal incision or
Fig. 29.2(a). Exposure of the retroperitoneum with underlying distal aorta
longitudinal incision over the groin and division of the and iliac vessels after retraction of the bowel cephalad and toward the
inguinal ligament may be necessary. opposite side.
258
Chapter 29. Iliac injuries
(b) (b)
HEAD
Ureter
Right CIA
External iliac a Internal iliac a
External iliac v
Fig. 29.3(a),(b). (cont.)
(a)
Aorta
Pelvis
Fig. 29.2(b). Retraction of the bowel cephalad and exposure of the Left CIA
retroperitoneum with underlying hematoma, secondary to iliac vascular injury.
The vessels can be exposed with an incision on the peritoneum, directly over Right CIA
the vessels, or by medial rotation of the left or right colon. Ureter
Left CIV
The ureter crosses over the bifurcation of the common iliac
artery and should be gently retracted with a vessel loop and
protected from accidental injury.
(a)
Left EIA
Left IIA
Fig. 29.4(a),(b). Left common iliac artery branching to external and

Ureter internal iliac arteries. The iliac veins are identified medial and posterior to the
arteries. The ureter crosses over the bifurcation of the common iliac artery to
the internal and external iliac arteries.
External iliac a Internal iliac a Exposure of the iliac veins is technically more challenging
than the iliac arteries, because of their position underneath
the arteries, especially on the right side. Some authors even
External iliac v recommend transection of the artery in order to gain
adequate access to the underlying vein. This approach is
not recommended, especially in a critically injured and
coagulopathic patient! Adequate venous exposure can be
Fig. 29.3(a),(b). Right common iliac artery branching to external and achieved with mobilization of the artery and gentle
internal iliac arteries. The external iliac vein is identified medial to the
artery. The common iliac vein courses under the artery. The ureter crosses
traction with vessel loops. Ligation and division of the
over the bifurcation of the common iliac artery to the internal and external internal iliac artery provides additional mobilization and
iliac arteries. better venous exposure.
259
Section 6: Abdomen
(b)
Left common iliac
artery
Spermatic vessels Retracted left ureter

Psoas Left CIA
Ureter
Left common iliac

Femorogenital n vein
Internal iliac a
Internal iliac v
External iliac a
External iliac v
Fig. 29.4(a),(b). (cont.)
Small arterial injuries without significant tissue loss may be Left external iliac
repaired with adequate mobilization of the vessel and artery
primary suturing. However, in most cases a more complex Left internal iliac
reconstruction with a size 6–8 synthetic graft is necessary. artery
Due to size mismatch, it is rarely possible to use a
saphenous vein autologous graft.
Iliac artery transposition may be a reconstruction option
in selected stable patients. The procedure involves
ligation of the proximal common iliac artery, near the
aortic bifurcation. The distal external and internal iliac
arteries are mobilized to allow for adequate length. The
contralateral common and external iliac arteries are
exposed. The injured artery is then anastomosed
end-to-side to the contralateral common or external Fig. 29.5. Mobilization and lateral retraction of the left common iliac artery
iliac artery (depending on anatomy), using a running, allows good exposure of the common iliac vein. Additional mobilization of
4–0 monofilament non-absorbable suture. the common iliac artery can be obtained by ligating and dividing the internal
iliac artery.
In patients in extremis consider early damage control
with temporary shunting. Semi-elective definitive
reconstruction is performed after patient stabilization. authors recommend venous reconstruction with patch
Venous repair with lateral venorrhaphy should be venoplasty or PTFE grafts, although there is no evidence of
considered in small injuries that can be repaired without improved outcome with this approach. Most surgeons do
producing significant stenosis (<50% of the lumen). In not recommend complex venous reconstructions, because
most cases the vein can safely be ligated. These patients these patients are often in extremis and any procedures that
should be monitored closely for extremity compartment prolong the operation may be counterproductive.
syndrome. In rare cases with post-ligation massive edema The best damage control option is temporary shunting.
of the leg, reconstruction with ring graft may be necessary. Ligation of the common or external iliac artery should be
The management of iliac venous injuries in the presence of avoided whenever possible to prevent irreversible limb
associated iliac artery injuries is controversial. Some ischemia.
260
Chapter 29. Iliac injuries
Fig. 29.6. The right common iliac artery after

HEAD transection and set-up for transposition to the left
common iliac artery.
Proximal divided end

of the right CIA
Left CIA
Left CIV
Exposure of the iliac veins is more difficult than exposure

of the arteries, because of their anatomic position. Good
mobilization of the artery and retraction with vessel loops
allows venous exposure. Ligation and division of the
internal iliac artery improves the exposure. Avoid the
recommendation by some authors to divide the common
or external iliac artery in order to improve the exposure of
External iliac artery the underlying vein.
Extra-anatomical bypass (axillofemoral or femorofemoral)
is rarely indicated at the acute stage. Its main indication is
in patients with postoperative graft infection.
If repair of the iliac vein produces significant stenosis,
consider anticoagulation and inferior vena cava filter
placement to prevent pulmonary embolism.
Some patients with iliac vascular injuries (especially in
Shunt combined arterial and venous injuries or prolonged
ischemia) develop extremity compartment syndrome.
In these cases a therapeutic fasciotomy should be
Fig. 29.7. External iliac artery injury with a damage control shunt in place. performed without delay, often before arterial
reconstruction.
The role of prophylactic fasciotomy is controversial
and has been challenged by many authors. If it is elected
Tips and pitfalls not to perform a fasciotomy, the patient should be
When clamping or mobilizing the iliac artery, proceed monitored closely with frequent clinical examinations,
cautiously to avoid iatrogenic injury to the underlying vein. serial CPK levels, and in the appropriate cases with
The ureter crosses over the bifurcation of the common iliac compartment pressure measurements. Fasciotomy
artery and is at risk of iatrogenic injury. Retract it out of should be performed at the first signs of compartment
the way with a vessel loop. syndrome.
261
Section 6 Abdomen
Inferior vena cava

Chapter
30 Lydia Lam and Matthew D. Tadlock
Surgical anatomy The IVC receives four or five pairs of lumbar veins, the
right gonadal vein, the renal veins, the right adrenal vein,
The inferior vena cava (IVC) is formed by the confluence the hepatic veins and the phrenic veins. It is of practical
of the common iliac veins, just anterior to the L5 vertebral
importance to remember that all lumbar veins are below
body, and posterior to the right common iliac artery. As it
the renal veins and that between the renal veins and the
courses superiorly towards the diaphragm, it lies to the
hepatic veins, besides the right adrenal vein there are no
right of the lumbar and thoracic vertebral bodies. It enters
other venous branches. The left lumbar veins pass behind
the thorax at T8, where the right crus of the diaphragm
the abdominal aorta.
separates the IVC and aorta. In most individuals, there is a
The confluence of the renal veins with the IVC lies
small segment of suprahepatic IVC, about 1 cm in length,
posterior to the duodenum and the head of the pancreas.
between the liver and diaphragm, which is amenable to
cross clamping. The retrohepatic IVC is about 8–10 cm in length and is
adhered to the posterior liver, helping to anchor the liver in
place. In this liver “tunnel” several accessory veins from the
caudate lobe and right lobe drain directly into the IVC.
Diaphragm There are three major hepatic veins that drain the liver into
the IVC. The extrahepatic portion of these veins is short,
measuring about 0.5 to 1.5 cm in length. The right hepatic
Hepatic veins vein is the largest. In about 70% of individuals, the middle
vein drains into the left hepatic vein to enter the IVC as a
single vein.
The thoracic IVC is almost entirely in the pericardium.
General principles
The IVC is the most frequently injured abdominal vessel
following penetrating trauma.
Blunt trauma to the IVC usually involves the retrohepatic
part of the vein.
Patients with intra-abdominal IVC injury, who present to
the hospital alive, typically have a contained retroperitoneal
hematoma and therefore may initially appear to be
hemodynamically stable.
Avoid femoral vein catheters in patients with penetrating
abdominal trauma, because of the possibility of proximal
Fig. 30.1. Anatomy of the inferior vena cava (IVC). Note the right renal artery iliac or IVC injury.
coursing behind the IVC.
In abdominal gunshot wounds obtain a plain abdominal
radiograph prior to going to the operating room if time
262
Chapter 30. Inferior vena cava
permits, as it helps determine missile trajectory and other (a)

structures at risk.
During induction of anesthesia in patients with severe HEAD
intra-abdominal bleeding, there is a high risk of rapid
hemodynamic decompensation or even of cardiac arrest.
The surgical team should be ready and the skin preparation
should be performed before induction of anesthesia.
During exploration of a caval injury, there is high risk for
air embolism. Prevent this complication by early direct
compression, followed by proximal and distal control.
Because of the extensive collateral circulation below the
renal veins, the infrarenal cava can be safely ligated with
acceptable morbidity of lower extremity swelling that is
usually temporary.
Following IVC ligation, the lower extremities and feet
should be wrapped with elastic bandages to reduce edema.
Monitor closely for extremity compartment syndrome.
Following packing or repair of IVC injuries, the patient
should not be over-resuscitated.

In addition to a standard trauma laparotomy instrument
tray, vascular clamps with multiple lengths and angulations
must be available.
A self-retaining retractor, such as Omni-Tract® or
Bookwalter®. Fig. 30.2(a). Addition of a right subcostal incision to the standard midline
laparotomy, for improved exposure of the liver. The subcostal incision is made
A sternotomy set should be available in case a median one to two finger breadths below the costal margin. Avoid an acute angle
sternotomy is needed for improved exposure of the between the two incisions to prevent ischemic necrosis of the skin.
retrohepatic IVC.
A surgical head light is important.
(b)
Patient positioning
Supine, with upper extremities abducted to 90 degrees.
Skin antiseptic preparation should include the chest,
abdomen, and groin.
Use upper and lower body warming devices.
Incisions
Extended midline trauma laparotomy, from xiphoid to
pubic symphysis.
The laparotomy may be extended through a subcostal
incision to provide exposure to the retrohepatic IVC (see
Chapter 20).
Fig. 30.2(b). A median sternotomy may be added to the midline laparotomy

in cases requiring access to the intrapericardial segment of the inferior vena
cava for vascular occlusion of the liver, or to the heart for placement of an
atrio-caval shunt.
263
Section 6: Abdomen
Exposure Retroperitoneal hematomas due to blunt trauma rarely

require exploration. However, large expanding or leaking
In penetrating trauma, upon entering the peritoneal cavity,
hematomas should be explored.
the usual findings include a large retroperitoneal
hematoma with or without free intraperitoneal bleeding. In The infrarenal and juxtarenal IVC is best exposed by
mobilization and medial rotation of the right colon, the
blunt trauma the most likely finding is a retroperitoneal
hepatic flexion of the colon, and the duodenum.
hematoma, usually retrohepatic.
The small bowel is eviscerated to the left of the patient and
Almost all retroperitoneal hematomas due to penetrating
kept in place with warm and moist towels. The avascular
trauma should be explored, irrespective of size, to rule out
white line of Toldt, lateral to the colon, is divided, using
an underlying vascular or hollow viscus injury. The only
sharp dissection or electrocautery. The cecum, right colon,
exception is a stable and non-expanding retrohepatic
and hepatic flexure are mobilized and retracted medially.
hematoma. Surgical exploration of the retrohepatic vena
cava or the hepatic veins is difficult and potentially Following the medial visceral rotation, the second portion
dangerous. of the duodenum, the Gerota’s fascia of the right kidney,
and the iliopsoas muscle are exposed.
The duodenum is then mobilized medially with the Kocher
maneuver, by incising the lateral peritoneal attachments of
the first, second, and proximal third portions of the
duodenum. The C-loop of the duodenum and the
pancreatic head are retracted medially to expose the
inferior vena cava posteriorly.
(a)
Liver
Duodenum
Fig. 30.4(a). Kocher maneuver: the lateral attachments of the duodenum

(arrows) are sharply divided, exposing the lateral and posterior surfaces of the
second portion of the duodenum.
Fig. 30.3. Medial rotation of the right colon combined with Kocher
mobilization of the duodenum provides good exposure of the inferior vena
cava, the right renal vessels, and the right iliac vessels.
264
(b) The IVC is then visualized with the aorta to the left of the
IVC. The paired renal veins and the right gonadal vein are
visualized draining into the IVC.
IVC
IVC
Duodenum
Renal veins Aorta

Fig. 30.5. Kocher maneuver with medial mobilization of the duodenum
exposes the inferior vena cava (IVC) and the renal veins.
Fig. 30.4(b). The duodenum is mobilized medially and the IVC is exposed.
Fig. 30.6. Exposure of the juxtarenal IVC, after Kocher maneuver and medial
visceral rotation.
Left renal vein
Right renal vein

IVC
Right gonadal
vein
265
Section 6: Abdomen
Fig. 30.7. Exposure of the IVC after medial

visceral rotation and Kocher mobilization of the
duodenum.
Right kidney
Right gonadal IVC

vein Aorta
Ureter
Circumferential infrarenal IVC control may be necessary in The initial hemorrhage control can be achieved by direct
cases where larger injuries or concern for posterior injury digital compression and subsequent application of a side
is suspected. The IVC should be carefully encircled with a vascular clamp, if possible. Alternatively, two sponge sticks are
right angle, taking care to avoid injury to the lumbar veins. placed above and below the IVC injury compressing the vein
against the vertebral bodies. Ligation or clipping of some of the
lumbar veins may be necessary for complete vascular control.
LIVER
DUODENUM
Left
renal vein
LIVER
IVC
Fig. 30.8. Control of the IVC can be achieved by encircling it, being careful
not to avulse any of the lumbar veins. Taking a medial to lateral approach IVC
will ensure no injury to the aorta.
Right
common iliac artery
Hemorrhage control and caval repair

Suprarenal, juxtarenal, and infrarenal IVC
In the unstable patient in extremis aortic inflow control by
either resuscitative thoracotomy (Chapter 4) or through
Fig. 30.9. Temporary bleeding control and prevention of air embolus with
the abdomen at the diaphragm (Chapter 19) may be compression with two sponge sticks, above and below the IVC injury,
necessary prior to IVC exposure. compressing the vein against the spine.
266
Many IVC lacerations can be repaired primarily with a 4–0 While some stenosis of the IVC after repair is of little
or 5–0 non-absorbable monofilament suture. consequence, more than 50% stenosis is associated with a
significant risk of thromboembolism. In these cases, other
(a)
options should be considered:
(a) Repair of the IVC with an autologous venous or
biologic or synthetic patch, sutured in place with a 4–0
or 5–0 non-absorbable monofilament suture.
(a)
HEAD
Left renal vein
Fig. 30.10(a). Primary repair of the IVC with nonabsorbable 4–0 or 5–0
monofilament is usually possible in most knife wounds and in some
low-velocity gunshot wounds.
(b)
HEAD
(b)
Fig. 30.10(b). Primary repair of the IVC with no significant stenosis.
(c)
Left renal vein
Right renal
vein
IVC
HEAD
Fig. 30.10(c). Primary repair of the IVC with significant stenosis. If the Fig. 30.11(a),(b). Synthetic or venous patches can be used to avoid >50%
stenosis is >50% of the lumen, there is an increased risk of thrombosis and stenosis for repair of the IVC. The patch is sutured in using a 5–0 or 6–0
pulmonary embolism. non-absorbable monofilament suture.
267
Section 6: Abdomen
(b) Place a caval filter above the area of stenosis. This can be Mobilize the IVC, rotate it medially, and repair the
done intraoperatively with the application of a caval clip injury being cautious of avulsing the lumbar veins.
or postoperatively with the insertion of a caval filter. An anterior caval venotomy is another option to access
(c) Ligation of the infrarenal IVC should be considered in a posterior injury. Once the posterior cava is repaired,
cases with extensive tissue loss or if the patient is in the anterior injury can be repaired primarily or with a
extremis. vascular patch, depending on the degree of stenosis that
The graft or patch should be covered with any surrounding results after primary repair.
tissues or omentum, to protect from infection or Complete reconstruction of the IVC with a prosthetic
pancreatic leaks. interposition graft inserted to re-establish IVC continuity, in
Exposure of posterior IVC injuries can be achieved selected cases involving the suprarenal IVC, which are not
through circumferential mobilization of the IVC or within amenable to simpler repairs. The injured portion is resected
the lumen through an anterior venotomy. and an end-to-end anastomosis to the IVC is performed with
a Dacron or PTFE graft. The graft must be 6 mm or larger.
(a)
(b)
Left renal vein
Repair, posterior Left renal vein
wall of the IVC
IVC
IVC
Repaired posterior
Retracted edges of
wall of the IVC
anterior venotomy
Fig. 30.12(a). Posterior IVC injury can be repaired through an anterior

venotomy. The anterior venotomy is usually present in penetrating injuries and
can easily be extended. Fig. 30.12(b). Completed repaired wound of the posterior wall of the IVC.
Fig. 30.13. Methods of reconstruction in

complex IVC injuries: interposition synthetic graft
(A), synthetic patch (B), repair of posterior wall
through anterior venotomy (C).
Repair of posterior wall
268
For juxtarenal injuries, ligation of the right renal vein Repair should be attempted, if technically
necessitates a right nephrectomy. The left renal vein can possible. The exposure of the laceration can be
be ligated close to the IVC, preserving the left gonadal improved by applying Allis or Babcock
vein, which provides adequate venous drainage. traumatic clamps, to control the bleeding and
The suprarenal cava is a very short segment of IVC pull down suprarenal injuries, facilitating
just below the liver and above the renal veins that is venorrhaphy.
difficult to expose.
(a) Fig. 30.14(a). The suprarenal IVC has no lumbar

veins and thus poor collaterals. Ligation of the IVC
in this location leads to renal failure, and increased
morbidity and mortality to the patient.
Caudate lobe
liver
Minor hepatic
vein
Suprarenal
IVC
Right renal
vein
IVC Left renal
vein
Fig. 30.14(b). Repair of high suprarenal IVC injury

(circle): using Allis or Babcocks to approximate the
(b) Head edges of the wound and pull it down, facilitating
exposure and repair.
LIVER Left renal

vein
Allis clamps
Traction on Allis forceps
269
Section 6: Abdomen
In cases with significant tissue loss a vascular patch can sternotomy, or a right thoracotomy, is needed for good
be placed. For complex injuries not amenable to simple visualization of the retrohepatic vessels.
venorrhaphy or a vascular patch, a synthetic A subcostal incision (see Fig. 30.2a) is the most
interposition or native vein graft can be utilized. common option and provides good exposure to the
Ligation of the suprarenal cava should be avoided posterior right lobe of the liver and to the retrohepatic
because it results in renal failure in all cases. However, vessels. Division of the falciform and coronary
in patients in extremis it might be the only option. ligaments should be performed to allow inferior-medial
Damage control procedures should be considered in rotation of the liver.
patients in extremis with severe coagulopathy, A right thoracotomy incision, through the 6–7
hemodynamic instability, or acidosis. They include the intercostal space to join up with the midline
following. laparotomy incision, and division of the diaphragm
(a) Ligation of the infrarenal IVC. straight down to the IVC diaphragmatic foramen,
(b) Placement of a temporary shunt and semi-elective allows exposure of the entire length of the retrohepatic
reconstruction at a later stage. A chest tube can be and suprahepatic IVC.
used, being mindful to include vents near the renal Extension of the laparotomy incision into a median
veins if the shunt traverses them. The shunt is secured sternotomy (see Fig. 30.2b) should be done only if an
with either vessel loops that are double looped and atriocaval shunt is planned.
secured with clips, or with a braided suture anchoring Complete vascular control of the retrohepatic IVC requires
the shunt in place. many steps: infradiaphragmatic clamping of the aorta,
followed by clamping of the infrahepatic IVC, the
suprahepatic IVC, and the portal triad (Pringle maneuver,
for hepatic artery and portal vein control).
Retrohepatic IVC Aortic control should always be done first, in order to
A retrohepatic hematoma or bleeding are suggestive of an reduce the risk of hypovolemic cardiac arrest. The
injury to the retrohepatic IVC or hepatic veins. technique is described in Chapter 28.
Characteristically, the bleeding becomes worse when the Suprahepatic IVC control can be achieved at two
liver is retracted anteriorly, and the Pringle maneuver is different locations:
not effective in controlling bleeding.
Exposure of the retrohepatic IVC is technically very – Between the liver and the diaphragm. In most
difficult and should be avoided, if possible. If the individuals there is typically a 0.5–1.0 cm portion of
hematoma is not bleeding actively or expanding rapidly, it the IVC where a vascular clamp can be placed.
should be left undisturbed. The liver ligaments should not Follow the falciform ligament posteriorly until the
be divided. hepatic veins and IVC is encountered and apply a
If the retrohepatic bleeding can be controlled with vascular clamp.
gauze packing, this technique should be the operative – In the pericardium: this approach requires the
treatment of choice and the operation should be addition of a right thoracotomy or a median
terminated. The patient should be returned to the sternotomy, as decribed above.
operating room for removal of the packing after
Infrahepatic IVC control is achieved by placing a
complete physiological stabilization of the patient, usually
suprararenal vascular clamp.
after 24–36 hours after the initial procedure. If after
removal of the packs there is still bleeding, repacking The portal triad control, or the Pringle maneuver, is
performed through the foramen of Winslow. The portal
should be done.
triad can be clamped or encircled with a vessel loop (see
The effective packing of the retrohepatic bleeding requires
Chapter 24).
posterior compression of the liver. The packs should be
placed between the liver and the anterior abdominal wall In extreme situations, the retrohepatic IVC injury can be
bypassed with the insertion of an atrio-caval shunt.
and also under the inferior surface of the liver. This
packing compresses the liver posteriorly, against the IVC, The laparotomy incision is extended into a median
and produces a more effective tamponade. No packs should sternotomy and the pericardium is opened.
be placed between the liver and IVC. A tape tourniquet is then applied around the
If the perihepatic packing is not effective in controlling intrapericardial IVC. The right atrial appendage is
bleeding, exposure and repair of the venous bleeding occluded with a vascular clamp and a 2–0 silk purse-
remain the only option. The standard midline laparotomy string suture is placed in the appendage. A size
alone does not provide appropriate exposure. Additional 8 endotracheal tube with a side hole cut at about
exposure through a subcostal incision, or a median 8 to 10 cm from the clamped proximal end of the
270
tube is then inserted through the purse-string. The Alternatively, a size 36 chest tube, with cut fenestrations
tube is guided by the surgeon into the IVC, the balloon in its proximal part, to allow blood from the IVC to
is inflated just above the renal veins, and the tape drain into the right atrium, might be used as a shunt.
tourniquet around the intra-pericardial IVC is A second tape tourniquet placed around the suprarenal
tightened. IVC is applied.
(a) Fig. 30.15(a). Exposure for placement of

atriocaval shunt requires extension of the midline
laparotomy into a median sternotomy.
HEART
LIVER
Diaphragm
(b) Fig. 30.15(b). Atriocaval shunt: a purse-string

suture is placed in the right atrium and the shunt is
inserted carefully caudad until the shunt is beyond
the renal veins.
Right Atrium
RIGHT LUNG HEART
Liver
271
Section 6: Abdomen
(c) Fig. 30.15(c). Atriocaval shunt in place.
Right Atrium
Shunt
LIVER
Inflated balloon
RIGHT LUNG IVC
Intrapericardial
IVC Right Renal Vein
(d)
Tips and pitfalls

In suspected abdominal vascular injuries, the femoral veins
should not be used for line placement, in case the victim
has an injury to the inferior vena cava or the iliac veins.
Appendix right
Resist the temptation to expose a contained retrohepatic
atrium IVC injury! A disaster is likely to occur!
In damage control, do not place packs behind the liver! The
liver should be compressed posteriorly against the IVC.
During mobilization of the infrarenal IVC, proceed
carefully to avoid injury to the lumbar veins. The avulsed
vein retracts and it is difficult to find it.
During exploration of a caval injury, there is high risk
for air embolism. Prevent this complication by early
direct compression, followed by proximal and distal
Balloon above
control.
renal veins Following IVC ligation, the lower extremities and feet
Renal veins should be wrapped with elastic bandages to reduce
edema. Monitor closely for extremity compartment
syndrome.
Fig. 30.15(d). Illustration of atriocaval shunt in place. Following damage control packing or repair of IVC
injuries, the patient should not be over-resuscitated.
After control of the inflow to the retrohepatic IVC is In the appropriate cases, consider placement of the
achieved, the retroperitoneal vessels are accessed by atriocaval shunt early, before the patient is in
inferomedial retraction of the liver, and the venous injury extremis. During placement of the atriocaval shunt,
is repaired with an interrupted or running 3–0 or 4–0 manually guide the tube into the IVC. It often curls
non-absorbable monofilament suture. into the heart!
272
Section 7 Pelvis
Surgical control of pelvic fracture hemorrhage

Chapter
31 Peep Talving and Matthew D. Tadlock
Surgical anatomy anterior ring disruptions. Hemorrhage following pelvic

fracture can occur from any branch.
Severe bleeding in complex pelvic fractures usually
The most commonly injured internal iliac artery branches
originates from branches of the internal iliac artery, the
(in decreasing order of frequency) are the superior gluteal,
presacral venous plexus, the fractured bones, and the soft
internal pudendal, and obturator arteries.
tissues. On rare occasions, it could be due to tear of the
major iliac arteries and veins. The superior gluteal artery is the largest branch of the
The abdominal aorta bifurcates into the two common iliac internal iliac artery. It exits the pelvis through the greater
arteries at the L4–L5 level. The iliac veins are located sciatic foramen, above the piriformis muscle. It provides
posterior and to the right of the common iliac arteries. The blood supply to the gluteus medius and minimus muscles.
ureter crosses over the bifurcation of the common iliac The internal pudendal artery passes through the greater
artery into the external and internal iliac arteries. sciatic foramen, courses around the sciatic spine, and
The internal iliac artery is about 4 cm long. At the level of enters the perineum through the lesser sciatic foramen.
the greater sciatic foramen, it divides into the anterior and The obturator artery courses along the lateral pelvic wall
posterior trunks. It gives numerous splanchnic and and exits the pelvis through the obturator canal. In about
muscular branches and terminates as an internal pudendal 30% of cases the obturator artery is perfused from both
artery, which is a potential source of hemorrhage in internal and external iliac arteries, making
angioembolization more complicated.
Fig. 31.1. Anatomy of the internal iliac artery. The
most commonly injured internal iliac artery
branches (in decreasing order of frequency) are the
superior gluteal, internal pudendal, and obturator
arteries.
Common iliac artery
External iliac artery Internal iliac artery

Superior gluteal artery
Internal pudendal artery

Obturator artery
273
Section 7: Pelvis
General principles and femoral artery access for catheter-based angiographic

embolization. Pelvic binders are contraindicated in major
The pelvic retroperitoneal space can accommodate 3–4 iliac wing fractures and has no role in closed book fractures.
liters of blood before venous tamponade occurs. Any
significant (>3 cm) pubic symphysis diastasis increases (a)
significantly the pelvic volume and reduces the
effectiveness of tamponade.
Complex pelvic fractures are associated with a high
incidence of intra-abdominal injuries and significant blood
loss. Nearly 30% of these fractures are associated with
intra-abdominal injuries and about 80% have multisystem
trauma.
The most common associated intra-abdominal injuries are
bladder and urethral injuries, followed by injuries to the
liver, small bowel, spleen, and diaphragm.
Patients with severe pelvic fractures should be admitted
under Trauma Surgery, for close monitoring for major
bleeding or possible intra-abdominal injuries, for at least
24 hours before transferring to the orthopedic service.
Hemorrhage in pelvic fractures originates from the
cancellous bone surfaces, pelvic vein plexuses, internal
iliac artery branches (15%–20%), and soft tissue injuries.
Pelvic vascular injuries involving the major iliac veins and
arteries occur in about 4%–10% of severe fractures. Fig. 31.2(a). Open book fracture with severe pubic symphysis diastasis is the
ideal indication for pelvic binder application.
Independent predictors of severe hemorrhage from the
pelvic fracture include persistent hypotension, contrast
extravasation on CT-imaging, large pelvic sidewall (b)
hematoma, sacroiliac joint disruption, symphysis diastasis
2.5 cm, bilateral and concomitant superior and inferior
pubic rami fractures (“Butterfly fracture”), age 55 years,
and female sex.
While the open anteroposterior compression, i.e., open
book pelvic fractures, are frequently associated with pelvic
vascular injury and hemodynamic compromise, whereas
closed book fractures are often associated with injuries to
urogenital and gastrointestinal structures.
A pelvic radiograph is useful in determining the need or
contraindication for application of a pelvic binder. Pubic
symphysis diastasis is an excellent indication for pelvic
binder application, while a fracture of the iliac wing is an
absolute contraindication. However, it often
underestimates the severity of the fracture and may miss
posterior fractures.
Fig. 31.2(b). A pelvic binder is applied to open book pelvic fractures,
reducing pelvic ring volume and hemorrhage.
Management of pelvic fracture bleeding
The majority of patients with bleeding from pelvic External pelvic fixation in the emergency room is rarely indicated
fractures can safely be managed with supportive measures, or performed, and there is no evidence that it is of any benefit.
such as pelvic immobilization, blood transfusions, and In a small number of patients with severe bleeding not
angioembolization. A massive transfusion protocol should responding to conventional therapeutic interventions,
be followed in the appropriate cases. damage control with pelvic packing may be life-saving. The
Pelvic binder is the first treatment to reduce the pelvic ring indications for operative management include severe
volume in an open book type pelvic fracture. Pelvic binders hemodynamic instability, need for laparotomy for
should be applied over the greater trochanters to associated intra-abdominal injuries, and failed or non-
appropriately reduce pelvic volume and allow laparotomy availability of angioembolization.
274
Chapter 31. Surgical control of pelvic fracture hemorrhage
Damage control operations (b)

There are two methods of damage control in severe pelvic
fracture bleeding: the extra-peritoneal approach and the
intra-peritoneal approach.
Special instruments
The optimal operating room is the hybrid operating room
with surgical and interventional radiology capabilities
simultaneously available.
Operating-table mounted laparotomy retractor systems Umbilicus
facilitate surgical exposure.
Major trauma laparotomy tray and vascular tray must be
available.
Large and medium clips and applier.
Vessel loops.
Local hemostatic sealants based on fibrin, thrombin,
collagen sponge, cellulose, microfibrillar collagen, and
bone wax facilitate local hemostasis and effective packing.
Angiography equipment with embolization coils and
Gelfoam particles.
Patient positioning
The patient is positioned in the supine position for trauma
laparotomy and resuscitative thoracotomy when
warranted. Skin preparation should include the chest,
abdomen, and lower extremities to the knees.
Access to the femoral artery below the inguinal ligament
should be available for interventional radiology.
Incision
Extra-peritoneal pelvic packing
An 8–10 cm skin incision is made midline below the umbilicus. Fig. 31.3(a),(b). (cont.)
(a)
Umbilicus
The midline fascia is exposed and incised down to the
peritoneum. The peritoneum is not entered. The prevesical
space of Retzius is now exposed.
While the clots are removed from the prevesical space, the
bladder and peritoneum are swept posteriorly to allow
effective packing.
Midline incision
Fig. 31.3(a),(b). Extra-peritoneal pelvic packing: a 8–10 cm skin incision is

made at the midline below the umbilicus to gain access to the
preperitoneal space.
275
Section 7: Pelvis
(a) (b)
Umbilicus
Peritoneum
Bladder
Incision of the
fascia
Fig. 31.4(a). The midline fascia is exposed and incised down to the Fig. 31.4(b). The prevesical space of Retzius (arrow).
peritoneum. The peritoneum is not entered.
(c)
Umbilicus
Space of Retzius
Bladder
Fig. 31.4(c). Blood is seen in the preperitoneal space (space of Retzius).

Peritoneal contents and the bladder are reflected posteriorly to facilitate
276 extraperitoneal pelvic packing.
Three laparotomy packs are inserted extraperitoneally (a)

along the pelvic sidewall on both sides of the bladder,
towards the sacroiliac joint and internal iliac vessels to
control bleeding originating from internal iliac arteries and
vein plexuses.
(a)
Umbilicus
Umbilicus
Peritoneum
Right packing
Pelvic sidewall
(b)
Umbilicus
Left packing
Fig. 31.6(a),(b). The fascia is closed over the extraperitoneal pelvic packing.
Fig. 31.5(a),(b). Packs are placed posteriorly towards the sacroiliac joint and
internal iliac vessels. Three packs are placed on each pelvic sidewall.
Following the packing, the rectus sheath is closed with a

running suture to facilitate effective tamponade.
Early angiography should be considered after the
extraperitoneal packing.
277
Section 7: Pelvis
(b)
Umbilicus
Pelvic hematoma
Bladder
Fig. 31.7. Operative photo depicting a pelvic hematoma associated with a

pelvic fracture. The sigmoid colon is reflected laterally to facilitate exposure.
The retroperitoneum is opened by medial mobilization of

the left or the right colon or by incising the
retroperitoneum directly over the common iliac artery
Fig. 31.6(a),(b). (cont.) bifurcation. The hematoma is evacuated and any obvious
major bleeding from the large vessels is controlled with
sutures, ligation, or repair.
Intraperitoneal damage control The common iliac arteries are dissected bilaterally and the
Rationale for intraperitoneal damage control: exploration internal iliac arteries are identified and isolated using
and management of associated abdominal injuries, direct right-angle clamps.
evaluation of major vessels and areas of bleeding, gauze Care must be taken to avoid injury to the ureters, which
packing of the bleeding area, and occlusion of internal iliac cross over the bifurcation of the common iliac artery into
arteries. the external and internal iliac arteries.
A formal exploratory trauma laparotomy is performed. Vessel loops are applied to both internal iliac arteries and
Any associated intraperitoneal injuries are identified and firm retraction is applied to occlude the pelvic arterial
treated. inflow.
Sigmoid colon is reflected laterally to the patient’s left to Surgical clips are placed on the retracted vessel loops to
expose the retroperitoneal hematoma, distal aorta, iliac facilitate the temporary vessel–loop–clip occlusion of the
artery bifurcations, and ureters when the hematoma is internal iliac artery. The procedure is performed bilaterally
decompressed and explored. for effective inflow occlusion.
278
(a) Following the vascular control and application of local

hemostatic sealants, pelvic packing, and temporary
abdominal closure are performed.
(a)
Left ureter
Left external iliac artery
Ureter
Left external iliac

artery
Left internal iliac artery Left internal iliac artery

Left external iliac vein
Left iliac vein
Fig. 31.9(a). Two clips (black circle) are placed on the vessel loop to facilitate
temporary occlusion of the internal iliac artery.
Fig. 31.8(a). The sigmoid colon has been reflected medially and the
retroperitoneum has been opened exposing the left external and internal iliac
arteries. The left external iliac vein is seen posterior and medial to the left
external iliac artery. (b)
(b)
Left external iliac

artery
Ureter
Left external iliac artery

Left internal iliac artery
Left external iliac vein
Fig. 31.9(b). A single clip (black circle) is placed across the internal iliac artery
to facilitate temporary occlusion.
Left internal iliac artery

Left external iliac vein Catheter-based angiogram of the aorta, lumbar arteries,
and the external iliac branches should be considered in
Fig. 31.8(b). The left internal iliac artery is isolated with a vessel loop. Note the appropriate cases.
ureter crossing over the external iliac artery.
The use of the vessel–loop–clip occlusion technique allows

vessel loop removal in the subsequent angiography setting Tips and pitfalls
for embolization following the surgical damage control. In the presence of a pelvic hematoma the FAST
Alternatively, the internal iliac arteries can be bilaterally examination may be unreliable in the diagnosis of
ligated or occluded using surgical clips. Surgical clip intra-abdominal hemorrhage. If the condition of the
placement allows clip removal and angioembolization in patient does allow CT scan evaluation, consider diagnostic
the postoperative phase of care when warranted. peritoneal aspirate.
279
Section 7: Pelvis
Failure to activate massive transfusion protocol early in the Avoid ligation of the internal iliac artery in cases with
management of the hemodynamically compromised acetabular fractures because it may interfere with
patient. subsequent surgical exposure and repair of the fracture.
Failure to appreciate the high incidence of intra-abdominal Inadequate knowledge of the anatomy of the iliac vessels
associated injuries. and their relationship to the ureter may result in iatrogenic
Failure to take the severely hemodynamically compromised injury to the ureter.
patient to the operating room for abdominal exploration
for associated injuries and possible damage control in the
pelvis.
280
Section 8 Upper Extremities
Brachial artery injury

Chapter
32 Peep Talving and Elizabeth R. Benjamin
Surgical anatomy
The brachial artery lies in the groove between the biceps
and triceps muscles. The proximal brachial artery lies
medial to the humerus and gradually travels lateral to lie
anterior to the humerus distally. At the antecubital fossa, it
runs deep to the bicipital aponeurosis and bifurcates into Median n
the radial and ulnar arteries, just below the elbow. The
Biceps m Brachial a
artery is surrounded by the two brachial veins, which run
on either side of the artery. At the upper part of the arm,
they join to form the axillary vein.
Ulnar n
The profunda brachial artery is a large branch arising from
the medial and posterior part of the proximal brachial
artery and follows the radial nerve closely. It provides
collateral circulation to the lower arm.
Aponeurosis
The basilic vein courses in the subcutaneous tissue in the
medial aspect of the lower arm. At the mid arm, it
penetrates the fascia to join one of the brachial veins.
The cephalic vein is entirely in the subcutaneous tissues,
courses in the deltopectoral groove, and empties at the
junction of the brachial and axillary veins.
In the upper arm, the median nerve is in front of the
brachial artery. It then crosses over the artery mid upper
arm and distally it lies behind the artery. Fig. 32.1. The brachial artery lies in the groove between the biceps and
triceps muscles. Note the close anatomical relationship with the median and
The ulnar nerve is behind the artery in the upper half of the ulnar nerves. In the upper arm the median nerve is anterolateral to the artery
arm. At about the middle, it pierces the intermuscular and at the middle it crosses over to course posteromedial to the artery. The
septum and courses more posteriorly, away from the artery bifurcates into the ulnar and radial arteries under the bicipital
aponeurosis, at the antecubital fossa.
artery, behind the medial epicondyle.
281
Section 8: Upper Extremities
(a) penetrating injuries or shotgun injuries may benefit from

preoperative imaging. “Soft signs” of vascular injury
include minor bleeding, stable small hematoma, and an
Axillary vein abnormal pulse index. In these cases arterial evaluation by
CT angiogram should be performed.
Cephalic vein
Hemorrhage from the brachial artery can be temporarily
controlled using direct digital compression or a proximal
Profunda brachial artery
tourniquet.
Ligation of the brachial artery is associated with a high
Superficial brachial artery incidence of limb loss and should not be done. In patients
in extremis a temporary shunt and delayed reconstruction
should be considered.
Basilic vein
In the event of a mangled extremity, the priority is
restoration of distal blood flow. This can be accomplished
Radial artery with shunt placement, external fracture fixation as needed,
Ulnar artery followed by debridement and definitive vascular repair.
Brachial artery injury is treated with primary repair or
autologous vein graft reconstruction. Synthetic grafts
below the shoulder have poor long-term patency.
Completion angiogram is indicated if there is any concern
regarding distal flow.
Intra- and postoperatively, patients with brachial artery
injuries should be monitored for compartment syndrome
Fig. 32.2(a). Anatomy of the major branches of the brachial artery and the with serial clinical examinations, compartment pressure
superficial and deep veins in the arm. monitoring, and serial blood creatine kinase (CK) levels.
Fasciotomy should be considered in appropriate cases.

In patients with suspected brachial artery injury, a vascular
tray is necessary.
(b)
A sterile tourniquet should be in the field for proximal
control.
A sterile Doppler probe should be available for perfusion
Venae comitantes
monitoring and an ultrasound for saphenous vein mapping.
Fogarty catheters, 3 and 4Fr should be available to clear the
Biceps vessel of clots.
Heparin solution for local use consisting of 5000 units of
heparin in 100 mL of normal saline.
An array of shunt sizes should be available to restore blood
flow in case immediate repair or reconstruction are not
possible. 15 cm Argyle shunts ranging from 8–14Fr should
be adequate for most injuries.
Brachial artery
If an angiogram is to be performed, C-arm fluoroscopy,
18G butterfly needle, and water-soluble contrast should be
available.
Fig. 32.2(b). Paired venae comitantes run on either side of the brachial artery.
Positioning
For a brachial artery injury, the patient is positioned in the
General principles supine position with the injured arm abducted 90 degrees,
“Hard signs” of extremity vascular injury, including externally rotated to face palm up with an arm table board.
pulsatile bleeding, expanding or pulsatile hematoma, Skin preparation should include the hand, circumferential
palpable thrill, audible bruit, absent peripheral pulse, and/ arm to the axilla, shoulder, neck and chest. The patient’s
or distal ischemia are a strong indication for immediate prepped hand should be covered with a sterile stockinette
operative exploration. Patients with multiple level or blue towel.
282
Chapter 32. Brachial artery injury
Potential operative needs to be considered during skin Exposure

preparation include access to the wrist and hand for
Access to the brachial artery requires superior retraction of
perfusion monitoring, forearm for compartment pressure
the biceps and inferior retraction of the triceps muscles in
monitoring, and the axilla and chest for emergent proximal
order to expose the neurovascular structures.
vascular control.
The brachial artery is covered by a fascial sheath within the
The bilateral groins should be prepared for possible vein harvest.
groove between the biceps and triceps muscles.
Incision (a)
The skin incision to expose the brachial artery is made

between the biceps and triceps brachii bellies that can be
extended proximally to the delto-pectoral groove for
axillary artery exposure. The incision can be extended
distally, curving towards the radius in the antecubital fossa
to expose the brachial bifurcation. The basilic vein is Fascia
Biceps m
identified and protected in the subcutaneous tissue in the Neurovascular bundle
lower part of the arm.
Fascia
(a)
Fig. 32.4(a). The neurovascular bundle runs between the biceps and triceps
brachii muscles, under the fascia.
(b)
(b) Biceps m
Fig. 32.4(b). Exposed neurovascular bundle.
In the proximal arm, the brachial artery lies just posterior

and medial to the median nerve and anterior and lateral to
the ulnar nerve. The basilic vein lies medial, outside the
Fig. 32.3(a),(b). The skin incision for brachial artery exposure extends brachial artery sheath. Once the muscle bellies are
proximally from the deltopectoral groove, along the groove between the retracted, the ulnar nerve and basilic vein should fall
biceps and triceps muscles, curving radially over the antecubital fossa (solid
line). For more proximal control at the axillary artery level, the incision is posteriorly with the triceps muscle and be out of the
extended into the deltopectoral groove (interrupted line). The incision can be operating field.
extended distally curving toward the radius in the antecubital fossa to expose
the brachial bifurcation (interrupted line).
283
The profunda brachial artery is a medial branch of Mid arm, the median nerve crosses over the brachial artery
the brachial artery in the proximal third of the and then courses medial to the artery as it bifurcates into
upper arm and is accompanied by the radial nerve. the radial and ulnar arteries at the antecubital fossa.
It is important to preserve this branch if not In order to access the brachial artery bifurcation, the
injured as it provides collateral circulation to the bicipital aponeurosis must be divided. Division of this
lower arm. aponeurosis has no clinical consequence and it does not
require reconstruction.
Fig. 32.5. Exposure of the brachial artery. The

median nerve is anterolaterally and the ulnar nerve
posteromedially. The ulnar nerve courses
posteriorly.
Median nerve
Brachial artery
Ulnar nerve
Fig. 32.6. The proximal brachial artery gives off a

profunda branch. This branch should be preserved,
Profunda brachial whenever possible, because it may provide
artery important collateral circulation to the lower arm.
Biceps
284
(a) (b)
Bifurcation brachial artery

Bicipital
aponeurosis
Radial a
Ulnar a
Divided
bicipital aponeurosis
Fig. 32.7(a),(b). Division of the bicipital aponeurosis at the antecubital fossa exposes the bifurcation of the brachial artery into the radial and ulnar arteries.
Vascular repair When definitive repair is feasible, debridement of the

injured segment to a healthy vessel is performed. If a
Once the injury is identified, proximal and distal control
temporary shunt is utilized, debridement of the injured
are obtained using bulldog clamps.
vessel is delayed until the time of definitive repair.
Fig. 32.8. Proximal and distal control of the

arterial injury (circle).
285
A 3Fr Fogarty catheter is passed proximally and distally to minimize the risk of intimal flaps and dissection. The more
clear the vessel of clots. technically complex anastomosis is created first, and the
Regional heparinization is achieved using heparinized artery is vented to release air bubbles prior to securing the
saline solution (5000 units in 100 mL normal saline), final suture line.
50 mL proximally, and 50 mL distally followed by After restoration of blood flow, distal pulses should be
reapplication of the vessel clamps. documented and the surgeon should consider an on-table
1 cm de heparina en 100 ml de sf angiogram prior to leaving the operating room if there is
(a) any question regarding flow.
Temporary shunt
When a temporary shunt is utilized as part of damage
control, a 0 silk tie is used to secure the shunt proximally
and distally. These ties are then tied together around the
center of the shunt.
The presence of distal flow must be confirmed after shunt
placement with Doppler ultrasound.
(a)
(b)
(b)
Fig. 32.9(a),(b). Prior to shunt placement, repair, or graft, the artery is cleared
of clot by proximal and distal passage of a 3Fr Fogarty catheter.
Prior to definitive repair, the proximal and distal ends of

the artery are trimmed using Potts scissors. The ends can
be beveled as needed for repair.
Small caliber arteries and the vein graft can be dilated using
a Fogarty catheter. Local anesthetic or papaverin can be
used regionally to counteract vasospasm.
Repair is achieved by primary repair or by utilizing a
reversed autologous vein graft as the conduit. A PTFE
interposition graft remains the last resort.
The vascular anastomosis is performed using a running or Fig. 32.10(a),(b). A temporary shunt is placed to restore distal blood flow.
A 0 silk tie is used to secure the shunt proximally and distally in order to prevent
interrupted monofilament suture with the needle passing accidental dislodgement. The profunda brachial artery is a proximal branch that
from the intima to adventitia on the artery side in order to provides collateral circulation to the lower arm.
286
Tips and pitfalls interfere with graft and wound healing and lead to
secondary infection.
The median and ulnar nerves are in close proximity
When sizing the length of the saphenous vein graft, it is
to the brachial artery and it is important to prevent
important to place the arm in gentle flexion of 10–20
iatrogenic nerve injury. High risk areas for injury
degrees. A common mistake is redundant graft length,
include ulnar nerve injury with initial exposure prior
which will lead to kinking of the graft.
to inferior retraction of the nerve with the triceps
brachii and injury to the median nerve as it crosses Arterial repair or anastomosis must be performed without
anteriorly over the brachial artery as they course down tension. In select cases, such as in knife wounds, gentle
the arm. mobilization of the proximal and distal ends of the artery
can allow primary anastomosis. In most cases with gunshot
During proximal brachial artery dissection, whenever
wounds or blunt trauma, a reversed interposition vein graft
possible, preserve the profunda brachial artery as it
is required.
provides significant collateral circulation to the lower arm.
During shunt placement, avoid debridement of the injured
A single individual should perform the Fogarty catheter
vessel. This should be performed at the time of definitive
passage. The resistance placed on the balloon during
reconstruction, in order to preserve as much normal artery
thrombus extraction is a dynamic process, and care must
as possible.
be taken not to exert excessive force on the intima and
create iatrogenic injury. Compartment syndrome of the forearm is a common
complication after brachial artery injury, especially with
After thrombus extraction, there should be generous
associated extensive soft tissue trauma or prolonged
forward and adequate backflow. If there is not adequate
ischemia. Evaluate intraoperatively and postoperatively for
flow prior to creation of the anastomosis, there is a risk of a
clinical signs of compartment syndrome. In appropriate
distal clot or missed injury.
cases measure the compartment pressures. Postoperatively
In the event of a destructive injury, it is important routine monitoring of CK levels is important. Consider
to adequately prepare the anastomotic bed by
early fasciotomy in appropriate cases (see Chapter 33).
debridement of all devitalized tissues. Failure to do so can
287
Upper extremity fasciotomies

Chapter
33 Jennifer Smith and Mark W. Bowyer
Surgical anatomy Common causes of forearm compartment syndrome

include vascular injuries, severe fractures, crush injuries,
The arm is divided into two muscle compartments: extrinsic compression devices such as casts and dressings,
The anterior compartment, which contains the biceps, extravasation of intravenous infusions, burns, edema from
the brachialis and coracobrachialis, all innervated by infection, and snakebites.
the musculocutaneous nerve. The diagnosis of compartment syndrome is made by a
The posterior compartment, which contains the triceps, constellation of clinical findings including tense
is innervated by the radial nerve. compartments and pain (usually out of proportion to that
The forearm is divided into three anatomic compartments. expected from the existing injury) with passive stretch of
The anterior or flexor compartment, which contains the the fingers. When conclusive evidence is not present, or
muscles responsible for wrist flexion and pronation of patients are not evaluable, compartment pressures may be
the forearm. There are a total of eight muscles innervated measured.
by the median and ulnar nerves, all receiving blood An absolute compartment pressure of >30 mm Hg or a
supply from the ulnar artery. The posterior or extensor delta pressure less than 30 mm Hg (diastolic blood pressure
compartment, which contains the muscles responsible minus tissue pressure) should prompt surgical
for wrist extension, is innervated by the radial nerve. The decompression.
blood supply is provided by the radial artery. Systemic blood pressure may have an effect on extremity
The mobile wad is a group of three muscles on the perfusion, so a lower absolute threshold for fasciotomy
radial aspect of the forearm that act as flexors at the should be considered in patients who are hypotensive.
elbow joint. These muscles are occasionally grouped Reversible muscle ischemia and neuropraxia occur in
together with the dorsal compartment. The blood up to 4–6 hours of ischemia time. Irreversible muscle
supply is provided by the radial artery and the ischemia and axonotmesis occur beyond 6 hours of
innervation by branches of the radial nerve. ischemia time.
The hand includes ten separate osteofascial compartments. The prognosis of acute compartment syndrome depends
upon the extent and duration of the pressure maintained in
The transverse carpal ligament, over the carpal tunnel,
is a strong and broad ligament. The tunnel contains the the compartment. Failure to decompress compartment
median nerve and the finger flexor tendons. syndrome will result in progressive muscle and nerve
ischemia, leading to paresthesia, paralysis, pulselessness,
and ultimately amputation.
General principles The most common muscle compartment in the upper
Compartment syndrome is a limb- and life-threatening extremity affected by compartment syndrome is the
condition. Renal failure due to myoglobinemia and anterior (flexor) compartment of the forearm. The upper
myoglobinuria is a common serious systemic complication arm is the least commonly affected, because it has a greater
due to delayed diagnosis. Volkmann’s ischemic contracture capacity to swell before the compartment pressures
is another complication resulting in permanent disability. increase.
288
Chapter 33. Upper extremity fasciotomies
Special surgical instruments (a) Fig. 33.1(a). The two

upper arm muscle
Basic orthopedic tray. compartments can be
® released through a single
Stryker intra-compartmental pressure measuring system
lateral skin incision from
using an 18-gauge side-ported needle is a readily available deltoid insertion to lateral
method for measuring compartment pressures (see epicondyle.
technique in Chapter 38).
For vessel–loop shoelace wound closure: vessel loops and
skin staples.
Negative pressure dressing system (NPDS).
Positioning
The affected arm is placed 90 degrees from the body on an arm
board. The entire chest, arm, forearm, and hand are prepped
into the surgical field.
Upper arm fasciotomy

The two upper arm muscle compartments can be released
through a single lateral skin incision from deltoid insertion
to lateral epicondyle.
At the fascial level two skin flaps are mobilized
anteriorly and posteriorly.
The intermuscular septum between the anterior and
posterior compartment is identified and the fascia over
each compartment is incised longitudinally.
Protect the radial nerve as it passes through the
intermuscular septum from the posterior compartment
to the anterior compartment just under the fascia.
289
(b) Fig. 33.1(b). Decompression of the two upper

arm compartments of the right arm, through a
lateral incision. The intermuscular septum between
the anterior and posterior compartments is
identified and the fascia over each compartment is
Anterior incised longitudinally.
compartment
Brachial
vessels
Lateral
incision
Posterior
compartment
Intermuscular
compartment
Forearm and hand fasciotomies approach utilizes two incisions (a dorsal and a volar
incision) to decompress the three compartments.
Incisions The most commonly described volar or anterior incision
A variety of incisions are described to decompress the three is the so-called “Lazy S.” The incision begins just proximal
compartments of the forearm. The most common to the antecubital fossa on the medial aspect of the forearm
Fig. 33.2. The standard volar and dorsal incisions

used to perform fasciotomy of the forearm and
the hand.
290
in the groove between the biceps and triceps. It is extended the forearm at the wrist. The incision is then carried
in a curvilinear fashion toward the radial aspect of the mid transversely to the center of the wrist and then carried on
forearm and then curved back toward the ulnar aspect of to the hand curving up on to the thenar eminence.
The skin flap of the forearm is then elevated and the
underlying fascia encasing the flexor muscle bellies are
exposed and opened with scissors.
At the wrist, the carpal tunnel is completely decompressed,
taking care to prevent injury to the median nerve found
just deep to the divided flexor retinaculum (transverse
carpal ligament).
Adequate decompression of the volar forearm and
palmar hand requires wide epimysiotomy (sectioning
of the muscle sheath) over all muscle bellies of the volar
forearm as well as carrying the incision well on to the
thenar aspect of the palm to completely decompress the
Fig. 33.3. The Lazy S incision used to open the volar (anterior) and mobile
wad (lateral) compartments demonstrated on the right arm. flexor retinaculum, which extends well beyond
the wrist.
(a) Fig. 33.4(a). Scissors are used to open the fascial

layers (arrows) (epimysiotomy) overlying the
muscle bellies of the volar (anterior) and mobile
wad (lateral) compartments as shown on the
left arm.
Left
thumb
(b) Fig. 33.4(b). Complete opening of all fascial

layers and decompression of all flexor muscles of
the left arm. The nerves should be protected.
Radial n
Medial n Radial art
Ulnar art
Ulnar n
291
(a) Median n
(b)
Right
thumb
Fig. 33.5(a). A completed fasciotomy of the left forearm demonstrating

complete epimysiotomy of the flexor muscles. The transverse carpal ligament
(circle), over the carpal tunnel, is a strong and broad ligament and extends well Fig. 33.5(b). The transverse carpal ligament (circle) with the underlying
beyond the wrist. Adequate decompression requires division of this ligament. median nerve.
(c)
Divided
transverse ligament (a)
Median n
Fig. 33.6(a). The incision for the decompression of the dorsal compartment
of the forearm extends from the elbow to proximal to the wrist.
Fig. 33.5(c). Division of the transverse carpal ligament and decompression of

the median nerve.
(b)
The posterior (dorsal) compartment is opened with

a longitudinal dorsal incision extending from the
elbow to the wrist (see Fig. 33.2), coursing between the
mobile extensor wad and the extensor digitorum
muscle bellies.
The hand includes ten separate osteofascial Left hand
compartments, which can be released with carpal tunnel
release and two dorsal incisions. For complete hand
fasciotomies, in addition to the division of the transverse
ligament over the carpal tunnel described above, two Fig. 33.6(b). Decompression of the dorsal compartment of the left forearm:
incisions are made on the dorsum of the hand over the the fascia over each of the muscle bellies is opened.
292
(a) Fasciotomy wound management

The wound should initially be left open to prevent
recurrence of compartment syndrome while the edema
decreases. A moist dressing should be placed on the muscle
bellies to prevent desiccation.
Negative pressure therapy dressing (VAC) is a useful
modality to manage the fasciotomy sites. It prevents wound
retraction, removes excessive soft tissue edema, and
facilitates delayed primary skin closure. However, its
application in the presence of incomplete hemostasis may
result in an increase in bleeding. It is advisable that this
dressing be used after the second look operation, when
hemostasis is complete.
Vessel–loop shoelace wound closure is a useful technique
to achieve delayed primary skin closure.
Split-thickness skin grafting may be necessary for wound
closure, if delayed primary closure is not possible.
Fig. 33.7(a). The interosseous compartments of the left hand are
decompressed via two incisions placed on the dorsum over the second and
fourth metacarpal spaces.
Tips and pitfalls
(b) Delayed diagnosis is the most common problem in the
management of compartment syndrome. A high index
of suspicion, serial clinical examinations, compartment
pressure measurements, and serial creatine phosphokinase
(CK) levels remain the cornerstone of early diagnosis and
timely fasciotomy. (The CK levels may be normal in cases
where delayed recognition of the compartment syndrome
results in completely dead muscle.)
Interosseous In suspected compartment syndrome the pressures should
compartments be measured in all muscle compartments. The pressures
may be normal in one compartment and abnormal in the
adjacent one.
Poor knowledge of the anatomy of the extremity muscle
compartments is the most common cause of incomplete
fasciotomy or iatrogenic damage to the neurovascular
bundle.
Extensor tendon
The muscle compartment responsible for the compartment
syndrome is usually obvious once the skin and fascia are
opened, and care should be taken to completely open the
fascia over any bulging and tense compartments.
Fig. 33.7(b). Dorsal fasciotomy of the left hand: the fascia over the
interosseous compartments are opened sharply, on either side of the tendons. The transverse carpal ligament is broader than
most surgeons realize, and adequate
second and fourth metacarpal spaces (see Fig. 33.2). decompression of the carpal tunnel requires full
The extensor tendons are retracted, and the underlying division of the ligament well up on to the thenar
compartments are opened with longitudinal slits on either eminence of the hand.
side of each tendon.
293
Upper extremity amputations

Chapter
34 Peep Talving and Scott Zakaluzny
Surgical anatomy Fig. 34.1. Anatomic

illustration of the upper
The upper arm has two muscle compartments, the anterior extremity with typical
arm and forearm
which includes the biceps muscle, and the posterior, which amputation sites.
includes the triceps muscle. Cephalic v
The forearm has two major compartments, the anterior
containing the flexor muscles, and the posterior containing Brachial a
the extensor muscles.
The upper extremity is perfused by branches from the
deep and superficial brachial artery. The proximal
brachial artery lies in the groove between the biceps and
triceps muscles. Distally, it courses in front of the humerus.
At the antecubital fossa, it runs deep to the bicipital
aponeurosis and bifurcates into the radial and ulnar Basilic v
arteries, just below the elbow. The artery is surrounded by
the two brachial veins, which run on either side of the
Radial a
artery. Ulnar a
The profunda brachial artery is a large branch arising
from the proximal brachial artery and follows the radial
nerve closely. It provides collateral circulation to the
lower arm.
The basilic vein courses in the subcutaneous tissue in the
medial aspect of the lower arm. At the midpoint, it
penetrates the fascia to join one of the brachial veins.
The cephalic vein is entirely in the subcutaneous tissues,
courses in the deltopectoral groove, and empties into the
junction of the brachial and axillary veins.
In the upper arm, the median nerve lies in front of
the brachial artery. It then crosses over the artery General principles
midway down the upper arm, where distally it lies behind In many trauma cases with a mangled extremity, primary
the artery. amputation may be preferable to multiple and often futile,
The ulnar nerve is behind the artery in the upper half of the salvage attempts.
arm. Midway down the arm, it pierces the intermuscular The level and type of amputation should be determined by
septum and courses more posteriorly, away from the the general condition of the patient, the functional status of
artery, behind the medial epicondyle. the limb, the type and severity of associated fractures, the
extent of soft tissue damage, the adequacy of blood supply,
and the availability of healthy skin flaps to cover the stump.
294
Chapter 34. Upper extremity amputations
Preserve as much functional length as possible to improve Compression wraps for postoperative dressings are helpful
prosthesis fitting and functionality of the remaining limb. to decrease edema and to shape the stump for early fitting
Use tourniquets to minimize blood loss. Elevation of the of prosthetics.
arm and the use of bandage or tourniquet exsanguinators
should be considered. The inflation pressure is usually set
at approximately 250 mmHg in adults or about 100 mmHg Patient positioning
above the systolic pressure. Supine position with the injured arm abducted 90 degrees
All non-viable tissues must be removed. on an arm table board.
Nerves should be sharply divided as high as possible and Skin preparation should include the hand, and the entire
allowed to retract. The ends of the nerves should be away arm circumferentially, including the axilla and shoulder.
from areas of pressure. The hand should be covered with a sterile stockinette.
Preserve sufficient soft tissues to cover the end of the bone A Doppler probe should be in the sterile field to assess
without tension. However, avoid excessive amount of soft arterial supply.
tissues because it may interfere with skin closure and Apply a sterile pneumatic tourniquet if possible.
prosthesis fitting.
Bone edges should be filed to remove any sharp edges.
Wounds should be closed without tension and suture lines
should be placed away from weight-bearing surfaces when
Above-elbow amputation
possible. Incision
In the multiply injured patient in extremis, a guillotine Perform a fish-mouth incision and create symmetrical
amputation should be considered. The definitive stump anterior and posterior flaps. The medial and lateral apexes
closure may be performed once the condition of the patient of the incision should be distal to the level of the planned
stabilizes. osteotomy.
For amputations proximal to the middle of the humerus,
preserve as much bone length as possible.
Special instruments For distal above-elbow amputation, preserve part of the
Use a wide arm table board to rest the injured extremity. humerus condyles to create a solid bone base for
Pneumatic tourniquet and bandage or tourniquet interaction with the prosthesis. If the condyles cannot be
exsanguinator. spared, remove at least 4 cm of the distal humerus to
Power saw or Gigli saw. facilitate prosthesis fitting with an elbow-lock mechanism
Bone files or rasps. that is equal in length to the contralateral arm.
Fig. 34.2. Essential instruments for amputations

in trauma: pneumatic tourniquet, bandage or
Pneumatic tourniquet tourniquet exsanguinators, power saw or Gigli saw,
bone files, or rasps.
Oscillating saw
with wrench
Periosteal
Bone rasps and elevator
files
Gigli hand
saw
Soft
tissue
retractor
Power
saw
blade
Traditional amputation knife
295
Fig. 34.3. Left arm amputation: fish-mouth incision with equal anterior and
posterior musculocutaneous flaps.
Elbow
Axilla
Procedure nerve located medially. The brachial artery is identified and

ligated.
The skin incision should be carried through the The median nerve is retracted gently and sharply divided.
subcutaneous tissue and fascia. This allows retraction of the nerve end into the soft tissues,
The brachial artery should be identified in the groove away from the load-bearing surface.
between the biceps and triceps muscles with the median
Fig. 34.4. Division of the left brachial artery. Note

its close proximity to the median nerve.
Left shoulder
Brachial artery
Divided biceps
muscle
Divided biceps
muscle
Median nerve
Triceps muscle
296
The ulnar nerve is located an inch posterior to the median

nerve on the medial aspect of the triceps muscle. Likewise,
the radial nerve is identified as it courses on the posterior
aspect of the humerus deep to the triceps muscle. These
nerves are divided, as described above.
Fig. 34.5. In the arm, the ulnar nerve is located

on the anteromedial aspect of the triceps muscle.
Left shoulder
Divided biceps
muscle
Triceps muscle
Ulnar nerve
The muscles are divided sharply to create the soft tissue

flaps. The posterior (triceps) muscle flap should be longer
to allow coverage of the bone upon closure.
Fig. 34.6. Photograph showing divided biceps

muscle, brachial artery, and median nerve. The
proximal median nerve has retracted under the
divided biceps muscle.
Left shoulder
Biceps muscle
Biceps muscle
Brachial artery
Median nerve
297
Fig. 34.7. Division of the triceps muscle is easily

performed over the hollow handle of the retractor.
Triceps muscle
The periosteum is elevated proximal to the skin and muscle The divided end of the humerus is then smoothed with
flap up to the point of planned bone division. The humerus a rasp.
is then divided with the power saw or Gigli saw.
(a) (b)
Periosteal elevator
Gigli saw
Triceps muscle
Fig. 34.8(a). Cobb’s periosteal elevator is used to clear the osteotomy site Fig. 34.8(b). Division of the humerus with the Gigli saw.
from the periosteum and soft tissues.
298
(c) (b)
Biceps muscle
Bone rasp
Triceps muscle
flap
Fig. 34.8(c). Bone rasp is utilized to smooth the edges of osteotomy. Fig. 34.9(b). Myoplasty (circle) using biceps and triceps muscles over the
humerus stump.
The triceps tendon is removed from the olecranon process; (a)

the posterior fascia of the triceps muscle is brought from
posterior, over the bone, and secured to the anterior fascia
of the biceps fascia anteriorly.
The skin is then closed over the fascial closure.
(a)
Biceps muscle Triceps muscle

flap
Fascia closure
Fig. 34.10(a). Closure of the fascia over the myoplasty.
Brachial artery (b)
Fig. 34.9(a). The triceps flap is used to cover the bone stump.
Fig. 34.10(b). A tension free skin closure completes the amputation.

299
Below-elbow amputation (b)
Incision
Perform a fish-mouth incision, with symmetrical anterior
and posterior flaps. The medial and lateral apexes of the
incision should be distal to the level of planned bone Left hand
division.
Wrist
Ulnar artery
Fig. 34.12(b). The ulnar artery is identified between the flexor digitorum
profundus and flexor carpi ulnaris muscles and ligated.
(c)
Elbow
Fig. 34.11. Left below-forearm amputation: fish-mouth incision with equal

anterior and posterior musculocutaneous flaps.
Radial artery
Procedure
The skin incision is carried through the subcutaneous Left hand
tissue and fascia.
The radial and ulnar arteries should be identified laterally
and medially, respectively, and ligated.
Similarly, the radial and ulnar nerves should be identified.
Traction should be applied to the nerves prior to sharp
Ulnar artery
division and ligation as described above.
The muscles are then divided. Adequate soft tissue should
be preserved to allow coverage of the bone. Avoid excess
Fig. 34.12(c). Photograph depicting volar aspect of the forearm amputation
with ligated radial and ulnar arteries.
(a)
(d)
Left elbow Radial artery

Median nerve
Left hand
Fig. 34.12(a). The radial artery is identified under the brachioradial muscle
and ligated. Fig. 34.12(d). Photograph showing the median nerve located on the
300 interosseous membrane in a deep aspect of the forearm.
muscle bulk, as it creates problems with skin coverage and (c)

the subsequent application of the prosthesis.
The median nerve lies deep, on top of the interosseous
membrane between the radius and ulna. The nerve is
sharply divided and ligated, as described above.
The periosteum is elevated proximal to the skin and muscle
Gigli saw
flap, up to the point of planned bone division. The radius
(a)
Ulna
Rad
ius
Left hand
Radius
Fig. 34.13(c). Division of the ulna with the Gigli saw.

Ulna
and ulna are divided separately at the same length with the
w
use of a power saw or Gigli saw.
elbo
Left Sharp ends of bone should be smoothed with a rasp.
The anterior and posterior deep fascia are re-approximated
and closed over the divided bones.
Fig. 34.13(a). Cobb’s periosteal elevator is used to clear the radius and ulna The skin is closed over the muscle.
of the periosteum and soft tissues.
(a)
(b)
Radius
Left elbow
Left hand
Ulna
Fig. 34.14(a). Photograph showing equal musculocutaneous flaps for closure

of the forearm amputation.
Fig. 34.13(b). Division of the radius with the Gigli saw.
301
(b)
Tips and pitfalls

Left elbow In many cases with a mangled extremity, primary
amputation may be preferable to multiple and often futile
salvage attempts.
Guillotine amputation with delayed reconstruction should
be considered in patients in extremis.
Preserve length to improve functional outcome, even if it
requires a skin graft or other plastics procedure for
coverage.
There is no difference in neuroma formation whether or
not the divided nerve is ligated. However, the transected
nerve ends should be retracted and located in a well-
cushioned tissue bed away from the load-bearing surface.
Fig. 34.14(b). Fascia closure (circle) is achieved using absorbable sutures.
(c)
Fig. 34.14(c). The stump is closed with a non-absorbable and tension-free

suture line.
302
Section 9 Lower Extremities
Femoral artery injuries

Chapter
35 George Velmahos and Rondi Gelbard
Surgical anatomy plane between the vastus medialis and adductor longus
and the adductor magnus covers the canal (see
The common femoral artery is a continuation of the Fig. 35.7).
external iliac artery and is approximately 4 cm long. It
The canal contains the femoral artery and vein, the
begins directly behind the inguinal ligament, midway
saphenous nerve which crosses from lateral to medial,
between the anterior superior iliac spine and the
and branches of the femoral nerve.
symphysis pubis.
The femoral vein courses from a medial position in the
The profunda femoris artery arises from the lateral aspect
groin to a posterior and then to a lateral position with
of the common femoral artery, towards the femur,
respect to the artery as it moves distally towards
approximately 3 to 4 cm below the inguinal ligament. The
the knee.
common femoral artery continues obliquely down the
anteromedial aspect of the thigh as the superficial femoral The greater saphenous vein courses medially to lie on
artery. the anterior surface of the thigh before entering the
fascia lata and joining the common femoral vein at the
The superficial femoral artery exits the femoral triangle to
sapheno-femoral junction near the femoral triangle.
enter the subsartorial canal and ends by passing through an
opening in the adductor magnus to become the popliteal
artery.
In the upper third of the thigh the femoral vessels
are contained within the femoral triangle (Scarpa’s
triangle).
The femoral triangle is formed laterally by the medial Sartorius m
border of the sartorius muscle, medially by the Adductor longus m
adductor longus and superiorly by the inguinal
ligament.
In the femoral triangle the femoral vein lies medial to
the femoral artery. The long saphenous vein drains into
the femoral vein about 3–4 cm below the inguinal
ligament. Further distally, the femoral vein lies
posterior to the artery and maintains this relationship
in the popliteal fossa. The femoral nerve and its
branches are found lateral to the common femoral
artery.
In the middle third of the thigh the femoral artery lies
within the adductor canal (Hunter’s canal), an aponeurotic
tunnel that extends from the apex of the femoral triangle to
the opening in the adductor magnus.
Fig. 35.1. Anatomical relationship of the femoral artery and vein as they
The adductor canal is bounded by the sartorius muscle course down the anteromedial aspect of the thigh. Note the femoral vein
anteriorly, the vastus medialis laterally, and the coursing from a medial position to a posterior and then lateral position with
adductor longus and magnus posteromedially. A fascial respect to the artery as it moves distally towards the knee (thick arrow).
303
Section 9: Lower Extremities
(a) General principles

The profunda femoris can be ligated without any problems.
However, ligation of the common or the superficial
femoral artery results in ischemia and loss of limb in most
patients. For patients requiring damage control, shunting is
always preferable to ligation.
Arterial reconstruction above the knee can safely be
Femoral nerve performed with a prosthetic or autologous graft. Injuries at
Common femoral artery the popliteal fossa should always be repaired with
Femoral vein autologous vein.
A Fogarty catheter should always be passed proximally and
Sartorius muscle
distally to remove any clots. Systemic heparinization can be
Adductor longus considered, but is not necessary if the patient is
muscle
coagulopathic or has multisystem injuries at risk of
bleeding. Local proximal and distal infusion of heparin
solution (5000 units in 100 mL of normal saline), however,
is recommended for routine use.
(b) At the completion of the arterial repair, examine for a
palpable peripheral pulse. On-table angiography should be
considered in cases where only a Doppler signal is detected.
The extremity compartments should always be monitored
peri-operatively. Routine prophylactic fasciotomies are not
indicated. However, therapeutic fasciotomies should be
performed without delay.
Common femoral Continued postoperative monitoring with serial clinical
Femoral nerve
artery examinations and serial serum creatine kinase (CK) levels
Femoral vein should be performed. Fasciotomy should be considered in
appropriate cases.
The femoral vein can usually be ligated with impunity.
Application of a compression bandage or elastic stocking
may reduce the degree of postoperative edema.
Fig. 35.2. Schematic (a) and photograph (b) showing the anatomy of the
right femoral triangle. The femoral vein lies medial to the femoral artery, while
the femoral nerve and its branches are found lateral to the femoral artery. Positioning
The patient should be placed in the supine position with
the hip and knee slightly flexed and externally rotated.
A bolster can be placed under the thigh and the knee.
Incision(s)
A vertical incision is made approximately halfway between the
pubic tubercle and the anterior iliac spine, directed towards the
medial femoral condyle. The length of the incision is deter-
Femoral artery mined by the site of the vascular injury.
Femoral vein
For proximal common femoral vascular injuries, the
Vastus medialis Adductor longus incision may have to be extended proximally through the
muscle muscle
inguinal ligament to gain adequate proximal control at the
external iliac artery level. It can also be curved superiorly
Sartorius
muscle
and laterally, parallel to the inguinal ligament, to allow for
retroperitoneal exposure of the iliac vessels.
For injuries to the superficial femoral artery, a longitudinal
incision is extended over the anterior border of the
Fig. 35.3. The adductor canal is bounded by the sartorius muscle anteriorly,
the vastus medialis laterally, and the adductor longus and magnus sartorius muscle. A useful external landmark is a line
posteromedially; a fascia between the vastus medialis and adductor longus and
magnus covers the canal.
304
Chapter 35. Femoral artery injuries
joining the middle of the inguinal ligament with the medial

femoral condyle.
Care must be taken to avoid injuring the greater saphenous
vein in its superficial location in the subcutaneous tissues,
along the medial edge of the incision.
Femoral artery
Sartorius muscle
Anterior superior
iliac spine
*
Inguinal ligament
Pubic tubercle
Site of incision
Fig. 35.5. Exposure of the common femoral artery through a standard vertical
incision. In order to expose the superficial femoral artery, the longitudinal
incision is extended over the anterior border of the sartorius muscle, along a
line extending from the anterior superior iliac spine to the medial femoral
condyle (interrupted line).
Fig. 35.4. Exposure of the common femoral vessels: a vertical incision is made,
starting approximately halfway between the pubic tubercle and anterior Common femoral
superior iliac spine, and with a direction towards the medial femoral condyle. artery
Profunda femoris
artery
Exposure and procedure Superficial femoral

Following the skin incision and dissection of the artery
subcutaneous tissue and superficial and deep fascia, the
femoral sheath is opened directly over the femoral artery,
using a combination of cautery and sharp dissection. The
femoral vein and the lymph nodes are medial to the artery.
A self-retaining Weitlaner or cerebellar retractor is placed.
The long saphenous vein is identified along the medial edge
of the incision, and preserved in case it is needed as an
autologous graft.
The common femoral artery is dissected circumferentially, Fig. 35.6. Medial and upward retraction of the common and superficial
and a vessel loop is placed around it for proximal control. femoral arteries allows exposure of the profunda femoris artery.
The same approach is followed for the superficial femoral
artery. aponeurosis, which forms its roof, and retracting the
The vessel loops around the common and superficial sartorius and vastus medialis muscles laterally and the
femoral arteries are retracted upwards and medially to adductor longus medially.
expose the profunda femoris artery, and a vessel loop is Distally, the superficial femoral artery is exposed by
placed around it. opening the aponeurotic roof of the adductor magnus
Exposure of the superficial femoral artery in the mid thigh canal. The very distal part of the artery exits from the
requires opening of the adductor canal by incising the adductor canal through the adductor magnus hiatus.
305
Fig. 35.7. Exposure of the distal superficial femoral artery requires opening of the
aponeurotic roof of the adductor canal (white box). The artery exits from the adductor
canal through the adductor magnus hiatus (white circle).
Superficial
femoral artery
In severely injured or unstable patients, or if the skillset of Although prophylactic fasciotomies are not
the surgeon precludes definitive repair, blood flow can be recommended, the patient must be closely monitored
restored temporarily using a shunt. Injuries to the common postoperatively for the development of compartment
femoral and superficial femoral arteries must eventually syndrome.
undergo definitive reconstruction. In hemodynamically stable patients, mannitol may be
The femoral vein can be ligated without any significant given intra- and postoperatively to decrease the risk of
problems. Repair should be considered only if it can be developing compartment syndrome.
performed with simple techniques and without producing Because lymphatics are abundant in this area, lymph
significant stenosis. Stenosis greater than 50% increases the vessels should be ligated or controlled with small
risk of thrombosis and pulmonary embolism. hemoclips to prevent formation of a lymphocele or lymph
At the completion of operation, the muscle compartments fistula. The saphenous vein and lymph nodes are medial to
of the lower leg should be evaluated and in appropriate the artery.
cases fasciotomies should be performed. Identification of the common and proximal
superficial femoral artery may be difficult in
cases with thrombosis and no pulse. Remember
Tips and pitfalls the external landmark, a line drawn from the
middle of the inguinal ligament to the medial femoral
Patients with combined venous and arterial injuries are at
condyle.
particularly high risk of developing compartment syndrome.
306
Popliteal artery
Chapter
36 Peep Talving and Nicholas Nash
Surgical anatomy The popliteal artery gives the superior and inferior
genicular branches, which provide blood supply to the knee
The popliteal fossa is diamond-shaped and its borders are joint and the surrounding tissues.
formed by the semi-membranosus and semi-tendinosus
Popliteal artery below the knee gives the anterior tibial artery
muscles superiomedially, the biceps femoris superolaterally,
and becomes the tibioperoneal trunk. The tibioperoneal
the medial head of the gastrocnemius inferomedially, and the
trunk gives the fibular artery about 2–3 cm distally, and
lateral head of the gastrocnemius inferolaterally. It contains
ultimately continues as the posterior tibial artery.
the popliteal vessels, the tibial and common peroneal nerves
and is covered only by subcutaneous tissue and skin. The anterior tibial artery pierces the upper part of the
interosseous membrane, courses in front of the membrane,
The popliteal artery is the continuation of the superficial
under the extensor muscles of the anterior muscle
femoral artery. It starts at the opening in the adductor magnus
compartment, and becomes distally the dorsalis pedis artery.
muscle, at the junction of the middle and lower thirds of the
thigh, and courses downward and laterally, between the two The posterior tibial artery is the continuation of the
condyles of the femur, into the popliteal fossa. popliteal artery, and is located under the gastrocnemius and
(a) Fig. 36.1(a). Anatomy of the right popliteal fossa:

the popliteal vein and tibial nerve are more
superficial and are lateral to the popliteal artery.
medial
lateral
Semi-tendinosus
muscle
Semi-membranosus
muscle Biceps muscle
Peroneal nerve
Popliteal vein
Tibial nerve
Popliteal a
Gastrocnemius muscle
Short saphenous v
Press. © Cambridge University Press 2015. 307
(b) dislocation without any delay and always evaluate

clinically, measuring the ankle brachial index and in the
appropriate cases perform a CT angiogram or color flow
Popliteal Doppler.
artery “Hard signs” of vascular trauma include active
hemorrhage, expanding or pulsatile hematoma, bruit or
thrill, absent pulses, and distal ischemia.
Most popliteal artery injuries due to firearm injuries or
blunt trauma require resectional debridement and
Anterior reconstruction with interposition vein graft. In rare
tibial occasions after a stab wound, an end-to-end primary
Tibioperoneal artery anastomosis may be possible.
trunk
In the presence of associated major orthopedic injuries, the
blood flow is restored with a temporary shunt, followed by
the orthopedic fixation. The definitive vascular
Posterior Fibular reconstruction is performed last.
tibial artery For patients requiring damage control or where the
artery surgeon skillset is insufficient to perform definitive
reconstruction, vascular shunting is the preferred method
of restoring flow. Ligation should not be performed due to
the high limb loss rate.
Dorsalis On-table completion angiogram should be considered
Lateral
pedis artery liberally if no good palpable pulse is obtained at the end of
plantar
(from top the operation.
artery
of foot) Always evaluate the lower leg for muscle compartment
syndrome, clinically and with pressure measurements.
Four-compartment fasciotomy should be performed in the
Fig. 36.1(b). Right popliteal artery posterior view: the anterior tibial artery appropriate cases (see Chapter 38).
pierces the upper part of the interosseous membrane (circle) and courses
in front of the membrane, in the anterior muscle compartment. The popliteal
artery then gives the peroneal branch, and continues as the posterior tibial
artery.
Special instruments
Head light, magnifying loupes.
soleus muscles and becomes superficial behind the medial Major vascular tray, vessel loops, Fogarty catheter (usually
malleolus. 3 Fr), sterile Doppler probe, Argyle shunts.
The popliteal vein and tibial nerve are more superficial and Device to measure muscle compartment pressures.
lateral in relation to the popliteal artery. Heparinized saline for regional heparinization (5000 units
heparin in 100 mL saline solution), papaverin solution, and
water-soluble contrast solution.
General principles
Injury to the popliteal artery is recognized as the most
limb-threatening of peripheral vascular injuries in Positioning
trauma and is associated with a high incidence of Supine position, the leg is positioned with slight flexion of
amputation. the knee supported with a bump, with the hip abducted
Popliteal artery occlusion or ligation results in a limb and externally rotated.
amputation rate of approximately 75%. Full skin preparation of the injured leg and the
Prognostic factors affecting limb salvage include the time contralateral groin, in case autogenous vein harvesting is
interval between injury and treatment with a goal of less required.
than 6 hours, mechanism, associated soft tissue injuries, If an external bone fixator is needed, it should be placed
and chronic vascular disease. after a temporary arterial shunt has restored distal flow,
Posterior dislocation of the knee is associated with a high with the knee in a slightly flexed position.
incidence of popliteal arterial injury. Reduce the
308
Chapter 36. Popliteal artery
Fig. 36.2. Position for exposure of the left

popliteal vessels: supine position, the leg in slight
flexion and external rotation of the knee, which is
supported with a bump.
Left thigh
Left
lower leg
Incision It continues distally, across the knee fold onto the

distal lower extremity, approximately 1 cm posterior
Mark the skin incision with marking pen. The to the tibia. The extent of the incision can be
incision starts proximally above the tubercle of the
adapted to the portion of the popliteal artery requiring
femur, about 1 cm posterior to the femur, between
intervention.
the sartorius muscle and the vastus medialis muscles.
Fig. 36.3. The incision starts about 1 cm posterior

to the femur, continues distally, across the knee
fold onto the distal lower extremity, approximately
1 cm posterior to the tibia.
Left knee
Left thigh
Left lower leg
309
During the skin incision, care should be taken to identify In the superior part of the incision, the groove
and preserve the saphenous vein, because it improves between the vastus medialis of the anterior thigh
venous drainage of the extremity, especially in the presence and the sartorius muscle is entered, with the sartorius
of a concomitant popliteal venous injury. being retracted posteriorly. The popliteal vessels
are located in the fat tissue right under the
distal shaft of the femur in the suprageniculate
Exposure position.
The dissection is carried on through the subcutaneous

tissues to the fascia, with care taken to avoid injury to the
saphenous vein, which should remain in the posterior flap.
Vastus medialis
FOOT
Sartorius
Saphenous vein
Fig. 36.5. Exposure of the left popliteal artery: the fascia of the thigh has been
entered and the sartorius (inferiorly) and the vastus medialis muscle (superiorly)
Fig. 36.4. Isolation and preservation of the saphenous vein are essential for have been exposed. The popliteal vessels are located in the fat tissue right
venous drainage of the extremity, in suspected cases with popliteal venous injury. under the distal shaft of the femur in the suprageniculate position (circle).
Fig. 36.6. The suprageniculate popliteal artery

(encircled by red vessel loops) and popliteal vein
exposed (blue vessel loop) with their accompanying
geniculate branches. Note the anatomical
relationship of the two vessels, with the artery being
medial to the vein above the knee.
Popliteal vein
FOOT
Popliteal artery
Hunter’s canal
Sartorius
310
The sartorius muscles covering the medial portion of the through the Hunter’s canal, if more proximal control
knee fold can be divided in sequential fashion, including is required.
the semi-membranosus, the semi-tendinosus, and the If more distal control is necessary, the remainder of the
gracilis muscles (pes anserinus). They should be tagged popliteal fossa can be opened by retracting the head of the
proximally and distally with different color sutures to allow gastrocnemius posteriorly, and detaching tibial
their reapproximation during closure of the wound for attachments of the soleus muscle.
optimal functional results.
The femur is palpated, and the dissection continues to
expose the neurovascular bundle directly behind the femur,
with the popliteal artery being the most medial structure Management of the injured vessel
first encountered, followed by the popliteal vein, and then After appropriate proximal and distal control is gained, the
the tibial nerve as the dissection continues laterally. injured portion of the vessel is resected back to
The dissection can be carried more proximally healthy edges.
towards the popliteal artery’s entry into the fossa
Fig. 36.7. Exposure of the infrageniculate

popliteal artery. The pes anserinus (composed of
the sartorius, gracilis, and semi-tendinosus tendons)
(circle) has been left in place to provide orientation.
The soleus muscle has been taken down from the
tibia to allow exposure of the popliteal vein (blue
vessel loop), the popliteal artery (red vessel loop),
and the tibial nerve (yellow vessel loop). This is the
Popliteal exact order in which each are encountered during
artery the dissection from medial to lateral.
Popliteal vein
Tibial nerve
Fig. 36.8. Exposure of the entire popliteal artery.

The pes anserinus has been divided, with each of
the ends marked after division with silk ties to allow
their reapproximation after the vascular repair. The
divisions of the popliteal artery into the
tibioperoneal trunk and the tibialis anterior artery
below the knee are marked with red vessel loops.
Tibialis
anterior
Popliteal artery Tibioperoneal trunk
311
A Fogarty balloon (3Fr) is then advanced both proximally The tension-free anastomosis is performed using a running
and distally to clear clots, followed by the injection of or interrupted monofilament 5–0 or 6–0 polypropylene
heparinized saline into the two ends. suture, with the needle passing from the intima to
Depending on the extent of the vascular injury, a reverse adventitia on the artery side, in order to minimize the risk
saphenous vein interposition graft for definitive repair or a of intimal flaps and dissection. The more technically
temporary shunt followed by an interposition graft is complex anastomosis is performed first.
performed. Small caliber arteries can be dilated using a Fogarty
Prior to definitive repair, the proximal and distal ends of catheter. Local anesthetic or papaverin can be used locally
the artery are trimmed using Potts scissors to healthy vessel to counteract vasospasm.
ensuring that intima is intact at the free edge. The ends can Distal flow is confirmed by a combination of physical
be spatulated as warranted for repair. examination and an on-table Doppler.
Fig. 36.9. Proximal and distal control of the

arterial injury with bulldog clamps.
Popliteal artery
Fig. 36.10. A temporary shunt can be utilized in

damage control setting or to restore perfusion
during the vein graft harvest.
312
If a temporary shunt has been utilized, a 0 silk tie is used to In the presence of associated extensive soft tissue damage,
secure the shunt proximally and distally. These ties are then the devitalized tissues should be excised and the vascular
tied together around the center of the shunt to prevent repair should be covered with surrounding healthy tissues.
dislodgement of the shunt. Prior to shunting, no
debridement of the arterial edges should be performed.
Tips and pitfalls

Failure to allow a 30-degree flexion when applying an
external fixator for fracture stabilization makes access to
the popliteal vessel very difficult.
Preservation of the saphenous vein during exposure of the
popliteal vessels is important in cases with suspected
popliteal vein injury, in order to preserve a good venous
drainage of the extremity.
In exposing the suprageniculate popliteal artery,
the sartorius muscle must remain inferior to the
dissection plane while gaining access to the Hunter’s
canal.
Failure to debride the anastomotic bed of all devitalized
tissues and cover the anastomosis at the end of the
procedure may result in graft infection and graft failure.
Arterial repair or anastomosis must be performed in the
Fig. 36.11. For popliteal artery repair, the reversed autologous venous graft is absence of tension. In select cases, gentle mobilization of
the only conduit utilized. the proximal and distal segments of the artery can allow
primary anastomosis. In most cases, however, a reversed
interposition vein graft is required.
Other considerations Failure to reapproximate the divided tendons may result in
knee instability.
A completion angiogram should be considered liberally, Perform routine postoperative monitoring of serum CK
especially in patients without the return of palpable pulses levels. Persistently elevated CK levels in patients without
post procedure. fasciotomies are highly suspicious for compartment
The four muscle compartments of the leg should be syndrome, and emergency fasciotomies should be
examined clinically, and if in doubt the compartment performed. Persistently elevated CK levels in patients with
pressures should be measured. Fasciotomies should be fasciotomies suggest incomplete fasciotomies or missed
performed in the appropriate cases. Postoperatively, muscle compartments and these patients should be
monitor serum CK levels. returned to the operating room.
313
Lower extremity amputations

Chapter
37 Peep Talving, Stephen Varga, and Jackson Lee
Surgical anatomy exsanguinators. The inflation pressure is often set at about

250 mmHg in adults or about 100 mmHg above the
Above and below the knee amputations require basic systolic pressure.
anatomy knowledge of the muscle compartments, nerves,
All non-viable or contaminated tissue must be removed
and arteries of the lower extremity.
and there must be sufficient arterial perfusion to allow
The thigh has three compartments: anterior, posterior, and
healing.
medial. The calf has four compartments: anterior,
Sufficient soft tissues should be preserved to cover the end
lateral, and posterior superficial and deep.
of the bone without tension. However, an excessive amount
The lower extremity is perfused by the superficial and deep of soft tissues may interfere with prosthesis fitting.
femoral artery. The superficial femoral artery continues as
The scars of weight-bearing stumps should preferably be
the popliteal artery after exiting the Hunter’s canal. The
posteriorly to the edge of the stump.
popliteal artery bifurcates into the tibialis anterior artery
and the tibioperoneal trunk that in the second order Nerves are divided as high as possible and allowed to
branches into the tibialis anterior and tibialis posterior retract. They should be divided sharply and ligated with
arteries. The femoral and sciatic nerves provide innervation non-absorbable sutures to reduce the risk of formation of
to the lower extremity. potentially painful neuromas. The ends of the nerves
should be away from areas of pressure.
Bone edges should be filed after transaction to remove any
General principles sharp edges, and all attempts should be made to maintain a
The goal with amputation surgery is a functional extremity myofascial layer between the bone and the skin.
with a residual limb that successfully interacts with the Wounds should be closed without tension, and suture
patient’s future prosthetic and external environment. lines should be placed away from weight-bearing surfaces
The rule of preserving as much length as possible is not when possible.
always applicable in the lower leg. Long leg stumps often do Drains can be used to reduce dead space and to drain
not heal well because of poor blood supply and do not residual bleeding.
tolerate prosthesis well.
A short below-knee stump is preferable to knee dislocation,
but a stump shorter than 6 cm may not be functional.
Optimal above the knee amputation level is between 12–18
cm below the trochanter major. Special surgical instruments
Use tourniquets to minimize blood loss. The cuff should Pneumatic tourniquet and bandage or tourniquet
not be placed directly over bony prominences, such as the exsanguinator.
head of the fibula or malleoli, to avoid the risk of direct Power saw or Gigli saw for the division of the bone.
nerve compression and damage. Elevation of the leg to Bone files or rasps are essential to smooth out bone edges.
empty the venous blood and reduce blood loss should be Compression wraps for postoperative dressings are helpful
done before inflation of the tourniquet cuff. This process to decrease edema and to shape the stump for early fittings
may be facilitated with the use of bandage or tourniquet of prosthetics.
314
Chapter 37. Lower extremity amputations
Fig. 37.1. Essential instruments for amputations

in trauma: pneumatic tourniquet, bandage or
tourniquet exsanguinators, power saw or Gigli saw,
Pneumatic tourniquet Oscillating saw bone files or rasps.
with wrench
Periosteal elevator
Bone rasps
and files
Gigli hand
Soft tissue saw
retractor
Power saw
Traditional amputation knife blade
Patient positioning Start with applying a pneumatic tourniquet if there is

enough femur length.
The patient is placed in the standard supine trauma
position with both arms at 90 degrees to allow anesthesia Mark with a marking pen a transversely oriented fish-mouth
incision. The anterior and posterior tissue flaps may be equal
access to the upper extremities.
or the anterior flap may be longer. The skin incision should
The leg should be prepped circumferentially and a pneumatic
be about 15 cm below the planned division of the bone.
tourniquet applied proximal to the injury to minimize blood
loss during the procedure. Padding or surgical towels can be The skin and subcutaneous tissue should be divided
circumferentially. The saphenous vein is identified in the
placed under the thigh to allow for elevation of the extremity.
medial aspect of the thigh and ligated.
The surgeon stands on the inner side of the leg for a better (b)
view of the vessels and nerves.
Above-knee amputation (AKA) RIGHT KNEE
The femur can be divided at any length necessary; most

commonly this is at the junction of the middle and distal
third of the femur shaft for optimal functional interaction
with the prosthetic limb (12–18 cm below the
trochanter major).
(a)
RIGHT THIGH
RIGHT KNEE
Fig. 37.2(a). Incision for right above-knee amputation: transversely oriented

fish-mouth incision. The anterior and posterior tissue flaps may be equal or the Fig. 37.2(b). Circumferential sharp dissection of the skin and subcutaneous
anterior flap may be longer. tissue of the fish-mouth incision.
315
The anterior thigh compartment muscles are sharply divided (a)

to the bone about 3–5 cm distal to the planned femoral
osteotomy. The divided muscles are reflected proximally.
The femoral artery and vein are identified deep to the
sartorius muscle and individually ligated and divided.
The transverse osteotomy is performed with a Gigli or power
saw and sharp edges should be filed down with the bone rasp.
Anterior thigh compartment
(a)
HEAD
Femur
Anterior thigh
compartment
RIGHT KNEE
RIGHT KNEE
Fig. 37.4(a). Periosteal elevator is used to clear the femur circumferentially of

soft tissue attachments.
Fig. 37.3(a). The anterior thigh compartment muscles are sharply divided to
the bone.
(b) (b)
HEAD

Anterior thigh
compartment
Gigli saw
Femur
Femur
KNEE
Fig. 37.4(b). A Gigli saw is used to divide the femur transversely.
The posterior thigh compartment muscles are sharply

KNEE divided an inch distally to the femoral osteotomy site. The
Fig. 37.3(b). The anterior thigh compartment muscles are reflected deep femoral artery is ligated when encountered,
proximally to expose the femur. depending on the level of AKA. The sciatic nerve is
identified, divided sharply, and ligated as high as possible.
316
(a) (b)
Distal femur
Proximal femur HEAD
Sartorius
HEAD muscle
KNEE
Anterior thigh
compartment Ligated
saphenous vein
Posterior thigh
Posterior thigh compartment compartment
Fig. 37.5(a). Sharp division of the posterior thigh compartment muscles. Fig. 37.5(b). Identification and ligation of the femoral artery and vein (white
circle).
(c)
HEAD
Sciatic nerve
Anterior thigh
compartment
Femur
HEAD
Anterior thigh
compartment
Posterior thigh
compartment
Fig. 37.5(c). Distal traction of the sciatic nerve with ligation and sharp Femur
division.
A periosteal elevator is utilized to separate periosteum

from the bone. Posterior thigh
compartment
Fig. 37.6. Periosteal elevator is used to separate the periosteum from the
femur in preparation for myodesis.
317
Myodesis is performed to attach and stabilize muscles Myoplasty is performed by bringing the quadriceps
directly to bone, facilitating fixed resistance against which a femoris over the bone and suturing to the posterior
muscle can move, to maintain function, and to provide fascia using interrupted absorbable sutures over the
distal padding of the osteotomy. Myodesis is performed by drains.
drilling four unicortical holes to the distal femur using a
2.5 mm drill screw to attach the adductor and medial (b)
hamstring muscles to the bone with three absorbable
HEAD
sutures.
Anterior thigh
compartment
(a)
Femur
HEAD
Posterior thigh
compartment
Anterior thigh
compartment
Adductor fascia
Fig. 37.7(b). Fascia of the adductor and medial hamstring muscles is attached
to the femur through the four unicortical holes with three absorbable sutures.
Femur
Posterior thigh
compartment
The skin is then closed with staples or interrupted 3–0
nylon vertical mattress sutures without tension.
Fig. 37.7(a). Drilling of four unicortical holes to the distal femur using 2.5 mm
drill screw for myodesis.
HEAD
Quadriceps femoris
Posterior muscle fascia
Fig. 37.9. Completed right above-knee amputation.
Fig. 37.8. Myoplasty over the femur. The quadriceps femoris is placed over
the bone and sutured to the posterior fascia using interrupted absorbable
sutures (white circle).
318
(a) (b)
HEAD
RIGHT KNEE
Anterior skin incision

Right
knee
Medial calf
FOOT
Anterior skin incision

Medial calf Posterior skin incision
Fig. 37.10(a). Right below-knee amputation: the anterior skin incision is

made transversely and located 10–12 cm or approximately one hand breadth
FOOT
below the tibial tuberosity and extended to both sides of the calf for a distance
of about one-half of the calf circumference.
Fig. 37.10(b). The posterior skin incision is marked along the vertical axis of
the leg for a length of one and a half times the transverse incision (12–15 cm).
The incision should be gently curved to reduce dog-ears in the closure.
Tips and pitfalls

Make sure to preserve as much femoral shaft length as
possible to improve function and prosthetic fit.
When making the anterior and posterior flaps, ensure there
is enough tissue for adequate coverage of the femur and RIGHT KNEE
that the flaps are able to come together without tension.
Be sure to flex the patient’s hip to check for tension on the Saphenous vein
skin suture line. If tension is present, the femoral shaft
requires further shortening.
Make sure to myodese the adductor and medial hamstrings
to the bone to prevent a non-functional and unstable
femoral stump. RIGHT FOOT
Medial calf
Below-knee amputation
The most commonly used amputation involves the
creation of a long posterior myocutaneous flap.
Mark the skin incision with a marking pen.
Inflate the pneumatic tourniquet.
The anterior skin incision is made transversely and located Fig. 37.11. Identification and division of the saphenous vein in the medial
10–12 cm or approximately one hand breadth below the aspect of the calf.
tibial tuberosity and extended to both sides of the calf for a
distance of about one-half of the calf circumference. Ligate
the saphenous vein when encountered in the medial aspect
of the leg. The anterior compartment muscles are divided sharply in
To construct the posterior flap, extend the skin incision the same plane as the transverse skin incision, and
along the vertical axis of the extremity for a length of one dissection is carried down until the anterior tibial artery
and a half times the transverse incision (12–15 cm). The and vein with the deep peroneal nerve are identified. The
posterior flap should be gently curved to reduce dog-ears in vessels are suture ligated with 2–0 silk sutures and the
the closure. nerve is retracted and divided sharply.
319
A periosteal elevator is used to clear muscular attachments transected with the power or Gigli saw 2–3 cm proximal to
to the tibia, and the interosseous membrane is divided the tibia transaction; any sharp edges should be filed down.
sharply. The fibula can be excised in young individuals.
The tibia is then divided using a power or Gigli saw
proximal to the skin incision in a plane perpendicular to
the long axis of the bone. The anterior lip of the tibia is RIGHT KNEE Divided
then beveled and filed down to remove any sharp edges. proximal tibia
(a)
Fibula
RIGHT KNEE
Medial calf
Tibia
FOOT
Anterior muscle
compartment
Fig. 37.13. Identification of the fibula with clearing of the soft tissue
circumferentially with a periosteal elevator and division 2–3 cm above the level
of the divided tibia.
FOOT
The posterior compartment muscles are divided in a plane

Fig. 37.12(a). Circumferential clearing of the tibia from the muscular
attachments.
below the distal tibia and fibula with a sharp amputation
knife to create the posterior muscle flap. Remove enough of
the soleus muscle to prevent excessive bulk or tension in
(b)
the flap closure.
The posterior tibial and peroneal vessels are identified and
ligated with 2–0 silk sutures. The tibial and peroneal nerves
RIGHT KNEE should be divided sharply under tension and allowed to retract.
The tourniquet should then be released and hemostasis
checked and achieved with suture ligation, attempting to
avoid electrocautery. The wound should then be irrigated,
Tibia
and the posterior flap rotated over a drain to cover the tibia
Gigli saw
and fibula.
The deep fascia is approximated with interrupted 2–0
absorbable sutures, ensuring a tension-free closure.
Medial calf The skin is closed with staples or interrupted 3–0 nylon
FOOT vertical mattress sutures.
Fig. 37.12(b). Division of the tibia with a Gigli saw.

Tips and pitfalls
Failing to make the posterior flap long enough to cover the
The lateral compartment muscles are divided sharply in the tibia will place the suture line under tension and will not
same plane as the transverse skin incision. The fibula is provide adequate soft tissue coverage of the bones.
identified and cleared of its muscular attachments Failure to make a gentle curve of the posterior incision will
circumferentially with a periosteal elevator. The fibula is result in excessive skin and dog-ears during the closure.
320
(a) (b)
RIGHT KNEE
Proximal tibia
Distal tibia
FOOT
Proximal tibia
Tibial nerve
RIGHT KNEE
Posterior muscle
compartments
Medial calf
Posterior muscle compartments
Fig. 37.14(a). Division of the posterior compartment muscles in a plane

below the distal tibia and fibula with a sharp amputation knife to create the
posterior muscle flap.
Fig. 37.14(b). Firm traction on the tibial nerve, followed by sharp division
very proximally (red arrow). The nerve stump is then allowed to retract.
(c) Removing too much of the soleus muscle in the posterior

flap will cause the soft tissue coverage of the bone to be too
thin and may cause pain and irritation of the skin. Leaving
RIGHT KNEE too much of the soleus muscle will create a bulky stump
and may add tension to the closure.
Failure to place the nerves under tension and divide them
sharply will prevent them from retracting and may result in
neuroma formation.
Proximal tibia
(a)
KNEE
Anterior muscle
compartment
Medial calf
Posterior muscle Tibia

compartments
Ligated posterior Medial calf

tibial vessles
Fig. 37.14(c). Beveling the anterior lip of the tibia (circle) to remove any
sharp edges.
Failure to transect the fibula 1–2 cm proximal to tibial

transaction will result in pain if left too long or if a conical Posterior muscle fascia
stump is left too short, either of which will be difficult to fit
Fig. 37.15(a). Rotation of the posterior muscle flap with closure of the
with a prosthesis. posterior muscle fascia over the tibia.
321
(b) The three major vascular bundles including the anterior

tibial artery and vein, the posterior tibial artery and vein,
and the peroneal artery and vein are ligated with 2–0 silk
sutures. The peroneal vessels are the most difficult to
control because of the difficult exposure between the tibia
and fibula.
If used, the tourniquet is released and hemostasis is
checked and achieved. Local hemostatic agents may be used
if necessary. Once hemostasis is achieved, a bulky moist
dressing is applied and covered by an ice wrap; then the
patient can be transported out of the operating room for
further resuscitation.
Fig. 37.15(b). Completed right below-knee amputation.

Postoperative care
Apply petroleum gauze over the skin incision and wrap the
Guillotine amputation (below knee) stump in a soft gauze dressing with a mild compression
wrap to help reduce edema and protect the wound from
The purpose of the guillotine amputation in the trauma trauma. If needed, a semi-rigid removable dressing may be
setting is to quickly remove the mangled extremity in a applied to help prevent contractures.
damage control situation with the plan to return to the Postoperative care of amputation patients requires
operating room in the future for a staged operation. multidisciplinary cooperation with rehabilitation
The knife is used to make a circular incision in an area of medicine, physical therapy, psychiatry services, and
viable tissue above the soft tissue requiring debridement. the surgical team. All must work coherently to get the
Sharp dissection is used to cut through the muscles and the patient ambulatory and fitted with a permanent
power or Gigli saw is used to transect the tibia and fibula. prosthesis as soon as possible.
322
Lower extremity fasciotomies

Chapter
38 Peep Talving, Elizabeth R. Benjamin, and Daniel J. Grabo
Surgical anatomy General principles

The lower extremity fascial compartments include three The compartment syndrome is a limb- and life-threatening
gluteal, three thigh, four calf, and nine compartments of condition. Renal failure due to myoglobinemia and
the foot. These compartments contain muscles, nerves, and myoglobinuria is a common serious complication in
blood vessels. delayed diagnosis.
The compartments of the buttock include the gluteus Extremity compartment syndrome may occur in patients
maximus, the gluteus medius/minimus, and the extension with severe fractures, crush injury, ischemia due to
of the fascia lata of the thigh into the gluteal region, which vascular injury, venous outflow obstruction,
forms the third compartment, the tensor fascia lata. The circumferential burns, and constricting bandages or casts.
sciatic nerve is the only major neurovascular structure in On rare occasions, massive fluid resuscitation in trauma
the compartments of the buttock. or burn patients may cause secondary compartment
The thigh has three compartments: the anterior syndrome.
compartment (quadriceps femoris and sartorius muscle), The variables affecting the severity of the compartment
the posterior compartment (biceps femoris, semi- syndrome include hypotension, compartment pressure,
tendinosus, and semi-membranosus), and the medial duration of elevated compartment pressure, perfusion
compartment (adductor muscle group and the gracilis pressure, and individual susceptibility. The compartmental
muscle). perfusion pressure is defined as the difference in pressure
The lower leg has four leg compartments: (mmHg) between the patient’s diastolic blood pressure and
The anterior compartment: contains the tibialis anterior measured compartmental pressure. A perfusion pressure of
muscle, extensor halluces muscle, extensor digitorum 30 mmHg or less is associated with a high risk of
longus muscle, the anterior tibial artery, and the deep compartment syndrome.
peroneal nerve. Compartment pressures > 30 mmHg or perfusion
The lateral compartment: contains the peroneus longus pressures <30 mmHg should prompt an emergency
and brevis muscles and the superficial peroneal nerve. fasciotomy.
The superficial posterior compartment: contains the Reversible muscular ischemia and neuropraxia occur in
gastrocnemius and soleus muscles and the sural nerve. up to 4–6 hours of ischemia. Irreversible muscular
ischemia and axonotmesis occurs beyond 6 hours of
The deep posterior compartment: contains the flexor
hallucis longus muscle, flexor digitorum longus muscle, ischemia.
tibialis posterior muscles, the posterior tibial artery, and The anterior and lateral compartments of the calf
the tibial nerve. are the most commonly affected by compartment
syndrome.
The foot contains a total of nine compartments including
four interosseous, the medial, lateral, deep and superficial Limited skin incisions may result in inadequate
central, and the adductor hallucis compartments that may decompression of the muscle compartments.
require decompression in crush injuries to the foot. The The fasciotomy skin incisions should always be left open.
medial, lateral, and superficial compartments pass through After decompression of the compartments, the viability of
the entire length of the foot, while the interosseous the muscles is ensured with diathermy or forceps-induced
compartments and the calcaneal compartments are contractions. Non-viable muscle mass is debrided and
confined to the forefoot and the hindfoot, respectively. hemostasis is ensured.
323
Special instruments The most commonly used technique is with the hand-held
® Stryker® device. An alternative in the ICU is to set up a
The Stryker intracompartmental pressure measuring
pressure transducer connected to a needle that may be
system using an 18-gauge side-ported needle is a readily
inserted into the muscle compartment.
available method for measuring compartment pressures.
Side-port needles are more accurate at measuring the
Basic orthopedic tray.
compartment pressure than regular needles.
For vessel–loop shoelace wound closure: vessel loops, skin
Steps for compartment pressure measurement with a
staples.
Stryker® device.
Negative pressure dressing system (NPDS).
1. Connect the side-port needle (A) to the diaphragm
chamber (B) and the diaphragm to the prefilled syringe
(C). Insert the assembled system into the device and snap
Technique of compartment pressure shut without forcing it (D). Turn unit on.
measurement 2. Press the zero button and wait for a few seconds until it
Excellent knowledge of the anatomy of the muscle shows zero.
compartments is critical! The pressure should be measured 3. Insert the needle perpendicular to the skin and insert into
in all compartments individually! Adjacent compartments the muscle.
may have very different pressures. 4. Slowly inject 0.3 mL into the compartment.
(a)
Stryker device
Side-port needle
Diaphragm chamber Prefilled syringe
Fig. 38.1(a). Pieces of the Stryker® device for the measurement of muscle compartment pressures.
(b) (c)
Side-port needle
Side-port needle
Prefilled syringe
Diaphragm
chamber
Digital display
Fig. 38.1(b). Side-port needle provides more accurate measurements of the Fig. 38.1(c). Side-port needle, diaphragm chamber, and prefilled syringe
muscle compartment pressures. assembled and placed in the device.
324
Chapter 38. Lower extremity fasciotomies
(d)
(b)
Left buttock
Digital
display
Fig. 38.1(d). The device is closed and is ready for use.
5. Wait for a few seconds for the display to reach equilibrium

before reading the pressure. Fig. 38.2(a),(b). (cont.)
The mid axial longitudinal incision begins just lateral to the

posterior superior iliac spine and extends posterolaterally
Gluteal compartment fasciotomy toward the lateral thigh. At the level of the trochanter, the
Patient positioning incision turns inferiorly along the lateral aspect of the thigh
to provide access to the fascia lata.
The gluteal compartment fasciotomies are performed in
the prone or lateral decubitus position. (a)
Incisions Head Posterior superior

iliac spine
Gluteal compartment decompression can be achieved
*
either through the traditional question mark incision or Left buttock
through a midaxial longitudinal incision.
The question mark incision starts at the posterior superior Posterior left
iliac spine, courses along the iliac crest, turns medially over thigh
the greater trochanter, and below the buttock and it
extends over the midline of the posterior upper thigh. *
(a) Greater trocanter

Posterior superior
iliac spine
* (b)
Left posterior
Left buttock thigh Head
Greater trochanter
Fig. 38.2(a),(b). Left buttock question mark incision for gluteal fasciotomy. Fig. 38.3(a),(b). Left buttock mid axial longitudinal incision for gluteal
fasciotomy. It begins just lateral to the posterior superior iliac spine and, at the
level of the greater trochanter, it turns inferiorly along the lateral aspect of the
thigh to provide access to the fascia lata.
325
Procedure (a)
The skin incision is carried through the subcutaneous

tissue to the fascia. The gluteus maximus is directly
encountered and the fascia is released.
Gluteus maximus
(a)
Head
Left buttock
Head
Left thigh
Fascia over
gluteus maximus (b)
Head
Fig. 38.4(a). Fasciotomy left buttock (patient in prone position): the skin Gluteus medius
incision is carried through the subcutaneous tissue and the fascia over the
gluteus maximus is exposed.
(b)
Divided fascia over

Head gluteus maximus
Gluteus maximus
Fig. 38.5(a),(b). Using a muscle spreading technique, the gluteus maximus is

divided along the lines of the fibers to access the underlying deep
compartment.
Non-viable muscle mass is debrided and hemostasis is

ensured. The wound is covered with NPDS or wet-to-dry
dressing.
Fig. 38.4(b). The fascia overlying the gluteus maximus is incised to allow
decompression of this compartment.
Thigh fasciotomy
Incisions
The muscle fibers of the gluteus maximus are split to access The entire extremity is prepared and draped from the iliac
the underlying gluteus medius/minimus compartment. crest to the toenails.
The inferolateral portion of the incision is used to release In most cases, one lateral incision is performed to
the tensor fascia lata. decompress both the anterior and posterior thigh
Following fasciotomy, the viability of the muscles is compartments. The medial compartment rarely needs
ensured with diathermy or forceps-induced muscle decompression, but if needed it can be accomplished
contractions. through a medial incision.
326
Procedure (a)
Lateral incision Head

The lateral incision decompresses both anterior and
posterior thigh compartments.
The skin incision extends from just below the greater Anterior compartment
trochanter to a few cm above the lateral femoral condyle. It
is carried through the subcutaneous tissue and down to the
fascia lata.
(a)
Posterior compartment
Left knee
Greater trochanter
Fig. 38.7(a). The fascia lata is divided with a longitudinal incision to
decompress the anterior compartment.
Lateral femoral condyle
(b)
Head
Anterior compartment
fasciotomy
Fig. 38.6(a). Fasciotomy left thigh: the skin incision extends from just below
the major trochanter to a few cm above the lateral femoral condyle.
(b)
Intermuscular septum Posterior compartment
fasciotomy Head
Left knee
Anterior compartment
Fig. 38.7(b). To decompress the posterior compartment, a posterior skin
Fascia lata flap is mobilized and an incision is made in the fascia posterior to the
intercompartmental septum.
Posterior compartment
(c)
Head Anterior compartment

fasciotomy
m
r septu
uscula
Interm
Fig. 38.6(b). The incision is carried through the subcutaneous tissue and
down to the fascia lata.
The fascia lata is divided with a longitudinal incision to Posterior compartment

decompress the anterior compartment. fasciotomy
To decompress the posterior compartment, a posterior

skin flap is mobilized and an incision is made in the fascia
posterior to the intercompartmental septum.
Fig. 38.7(c). Left thigh fasciotomy: decompression of the anterior and

posterior compartments through fascial incisions in front of and behind the 327
intermuscular septum.
Anterior compartment Fig. 38.8. Left thigh fasciotomy through a lateral

fasciotomy incision: the posterior compartment can be
decompressed through the intercompartmental
septum, which can be accessed and incised (red
Anterior arrow) by retracting the exposed vastus lateralis
compartment muscle superiorly and medially.
Medial
compartment
Posterior
compartment
fasciotomy
Posterior
compartment
Alternatively, the intercompartmental septum can be (a)

accessed and incised by retracting the exposed vastus
lateralis muscle superiorly and medially with large
retractors.
Subsequently, the lateral intermuscular septum between
anterior and posterior compartments is incised for the Left knee
length of the incision.
Medial incision
This incision is rarely needed because the medial muscle Medial femoral
compartment is rarely affected. condyle
By decompressing the anterior and posterior
compartments, pressures in the medial compartment
secondarily drop as well. Measure the medial compartment
pressures before proceeding to fasciotomy.
In the average size male, a 20- to 25-cm medial incision Fig. 38.9(a). Left medial thigh fasciotomy incision: the incision courses along
courses along the greater saphenous vein, extending to a the greater saphenous vein extending to a few cm above the medial femoral
condyle.
few cm above the medial femoral condyle.
If decompression of the medial compartment is warranted,
the saphenous vein should be preserved.
328
(b) Fig. 38.9(b). Completed left medial thigh

fasciotomy incision.
Head
Adductor muscles
Gracilis muscle
Lower leg fasciotomy The lateral incision decompresses the anterior and lateral
compartments.
Incisions The medial incision decompresses the superficial and deep
The standard four-compartment fasciotomy of the lower posterior compartments.
leg is achieved through two incisions.
Fasciotomy of the Fig. 38.10. Four-compartment fasciotomy of

anterior and lateral the right leg through two incisions. The lateral
incision decompresses the anterior and lateral
compartments Fasciotomy of the compartments and the medial incision
Anterior
posterior superficial and decompresses the superficial and deep posterior
compartment compartments.
deep compartments
Lateral
compartment
Deep posterior
compartment
Superficial posterior
compartment
329
Lateral incision The anterior compartment is decompressed through a

fasciotomy, about two to three finger breadths lateral to the
The lateral incision is performed midway between the
lateral tibial edge, anterior to the septum separating the
fibula and the lateral tibial edge (or about two finger
anterior from the lateral compartments. As mentioned
breadths in front of the fibula), starting two to three finger
above, the septum is approximately under the skin incision.
breadths below the tibial tuberosity and extending to two to
Perforating vessels entering the septum may facilitate
three finger breadths above the ankle. This incision is
identification of the septum. Another method to identify
approximately over the septum separating the anterior
the septum is a transverse incision over the estimated site
from the lateral compartments. A useful external landmark
of the septum. Decompression of the anterior
for the fibula is a line drawn from the head of the fibula to
compartment is achieved through a longitudinal
the lateral malleolus.
fasciotomy with long, blunt-pointed scissors. The scissor
The skin incision should be carried through the tips are always turned away from the septum. The
subcutaneous tissue and down to the investing leg fascia.
fasciotomy is directed towards the big toe distally and the
Skin flaps are raised to expose the fascia covering the
patella proximally.
anterior and lateral compartments of the leg.
(a) Fig. 38.11(a). Fasciotomy of the left lower leg.

The lateral incision is made midway between the
Head fibula and the lateral tibia edge starting two to
three finger breadths below the tibial tuberosity
and extending to two to three finger breadths
Tibial tuberosity above the ankle.
Lateral malleolus
(b) Fig. 38.11(b). Lateral incision for left leg

fasciotomy. The skin incision is carried down to the
investing leg fascia. Skin flaps are raised to expose
the fascia covering the anterior and lateral
compartments of the leg. Note the septum
between the anterior and lateral compartments.
Care should be taken to avoid injury to the
Inter-compartment Anterior superficial peroneal nerve, in the lower part of
septum compartment the leg.
Superficial peroneal
nerve
Lateral
malleolus
Lateral
compartment
330
The lateral compartment is decompressed with a lateral malleolus is critical in order to avoid injury of the
longitudinal incision behind the intercompartmental superficial peroneal nerve, as it pierces the septum in the
septum. The fascia is incised with a direction towards the distal third of the leg to take a subcutaneous course.
lateral malleolus distally and the head of the fibula
proximally. Directing the distal fasciotomy towards the
(a) Fig. 38.12(a). Left leg fasciotomy, lateral incision.

The anterior compartment is decompressed
through a fasciotomy, about two to three finger
breadths lateral to the lateral tibial edge, anterior to
the septum separating the anterior from the lateral
compartments.
Superficial
peroneal
nerve Anterior
compartment
Lateral
compartment
Head
(b) Fig. 38.12(b). Identification of the septum,

which separates the anterior and lateral
compartments. The lateral compartment is
decompressed with long scissors.
Anterior
compartment
Septum
Lateral compartment
Head
331
Medial incision The skin incision is carried through the subcutaneous

tissue and down to the investing fascia taking care to
The medial incision is performed two finger breadths
identify and preserve the saphenous vein facilitating
posterior to the medial edge of the tibia starting two to
venous outflow from the leg.
three finger breadths below the knee and extending to two
to three finger breadths above the ankle.
(a) Fig. 38.13(a). The medial incision is placed

approximately two finger breadths posterior to the
medial border of the tibia, starting two to three
finger breadths below the knee and extending to
two to three finger breadths above the ankle.
Left
knee
Left medial
malleolus
(b) Fig. 38.13(b). Left leg fasciotomy, medial

incision: The incision is carried down to the fascia
and skin flaps are slightly mobilized.
Head
Left
knee
Left medial
malleolus
Fascia overlying superficial

posterior compartment
332
The superficial compartment is decompressed with a Foot fasciotomy

fascial incision, made about two finger breadths posterior
The most common cause of foot compartment syndrome is
and parallel to the medial fasciotomy.
crush injury.
The deep posterior compartment is decompressed with a
fascial incision just behind the edge of the tibia.
Identification of the posterior tibial neurovascular bundle
Incisions
ensures that the deep compartment has been properly The compartments of the foot are usually decompressed
identified. through three incisions: one medial incision and two dorsal
incisions over the interosseous compartments.
Procedure
(a)
The medial incision extends from a point below the medial
malleolus to the metatarsophalangeal joint. This incision
risks injury to the neurovascular bundle and some
surgeons avoid it in favor of only two dorsal incisions.
The two dorsal incisions are placed over the second and
fourth metatarsal shafts. Maintain a wide skin bridge to
avoid necrosis. Skin flaps are raised to identify each of the
Tibia
Deep posterior interosseous compartments.
compartment
(a)
compartment
Septum
Fig. 38.14(a). Left leg fasciotomy, medial incision. The superficial

compartment is decompressed with a fascial incision, made about two finger
breadths posterior to the tibia. The deep posterior compartment is
decompressed through a fascial incision just behind the edge of the tibia.
(b) Dorsal incisions
Fig. 38.15(a). Foot fasciotomy. The two dorsal incisions are placed over the
second and fourth metatarsal shafts.
(b)
Left
knee
Deep posterior compartment

compartment
Left medial
malleolus
Fig. 38.14(b). Identification of the posterior tibial neurovascular bundle (red

vessel loop) ensures that the deep compartment has been properly identified.
Fig. 38.15(b). The interosseous compartments are identified and opened.

333
(a) (a)
Medial
incision
Fig. 38.17(a). Vessel-loop shoelace wound closure of the fasciotomy wound.

(b)
(b) Fig. 38.17(b). Negative

pressure therapy of a left
buttock fasciotomy.
Left buttock
Fig. 38.16(a),(b). Foot fasciotomy: medial incision.
Fasciotomy wound management Split-thickness skin graft may be necessary for wound
closure, if delayed primary closure is not possible.
Negative pressure therapy dressing (VAC) is a useful
modality to manage the fasciotomy sites. It prevents wound
retraction, removes excessive soft tissue edema and
facilitates delayed primary skin closure. However, its
application in the presence of incomplete hemostasis may
Tips and pitfalls
result in severe bleeding. It is advisable that this dressing is Delayed diagnosis is the most common problem in the
used after the second look operation, when hemostasis is management of the compartment syndrome. A high index
complete. of suspicion, serial clinical examinations, compartment
pressure measurements, and serial CK levels remain the
Vessel-loop shoelace wound closure is a useful technique to
cornerstone of early diagnosis and timely fasciotomy.
achieve delayed primary skin closure.
334
The CK levels may be normal in delayed recognition of the The deep posterior compartment of the lower leg is the
compartment syndrome and completely dead muscle. most commonly missed or incompletely released
In suspected compartment syndrome, the pressures should compartment. The easiest location to identify the deep
be measured in all compartments. The pressures may be posterior compartment is distal in the calf.
normal in one compartment and abnormal in the Short skin incisions may result in an inadequate fasciotomy
adjacent one. and progression of the ischemic neuromuscular damage or
Poor knowledge of the anatomy of the extremity muscle renal failure.
compartments is the most common cause of incomplete Open fractures do not preclude compartment syndrome in
fasciotomy or iatrogenic damage to the neurovascular the affected compartments.
bundle.
The superficial peroneal nerve is the most commonly
injured nerve.
335
Section 10 Orthopedic Damage Control
Orthopedic damage control

Chapter
39 Eric Pagenkopf, Daniel J. Grabo, and Peter Hammer
General principles stabilized fractures. Placement of this hardware requires a

set of specialized tools, generally available in any facility
The treatment goals of damage control surgery in that treats patients with orthopedic injuries.
orthopedics (DCO) include the following.
Instrument trays are manufactured by several different
Improving vascular flow and subsequent tissue companies but all will share similar components.
perfusion by reducing and realigning long bone
Pins: placed into the cortex of the bone as the anchor
fractures.
point for the external fixator.
Treatment of open fractures and associated soft tissue
Pin clamps: secured around two pins, providing the
wounds.
bridge between the pins and the connecting rods. Each
Stabilizing long bone fractures. pin clamp can be affixed with two posts (straight, 30
Giving priority to other more severe, life-threatening degree, 90 degree) and can be rotated into 12 different
associated injuries. positions, thus giving maximal flexibility to the
Through these goals, patients will have reduced pain, decreased structure of the external fixator.
blood loss, and a lower systemic inflammatory response.
Pin-to-rod coupler: can connect a pin to a connecting
rod when a pin clamp is not used.
Special equipment Rod-to-rod coupler: can connect a connecting rod to a
Damage control surgery in orthopedics is centered around post or another connecting rod.
the placement of external fixators on both reduced and Drill: can be either pneumatic-driven or battery powered.
Fig. 39.1. A representative sample of equipment

Drill loaded with self-drilling pin found in a standard external fixator set.
90 Degree
angled posts
10 Hole 30 Degree
pin clamps angled posts
Straight
posts
Self-drilling pins
Centrally
threaded
Couplers Carbon pin
connecting
5 Hole pin clamps
rods
with angled posts
337
Section 10: Orthopedic Damage Control
For pin selection, the choice is between a blunt and a Management of specific fractures
self-drilling pin. Blunt pins require pre-drilling of holes
in the cortex. Self-drilling pins can be mounted directly Mid shaft tibia fracture
on to the drill and drilled into place. After the decision has been made to stabilize a tibial
Another screw that may be necessary is a centrally fracture with an external fixator, the locations of the
threaded pin. This long pin has a self-drilling tip, but anchoring pins must be decided. Two pins should be
the threads are located in the middle of the pin, not at placed on each side of a fracture site. One pin is inadequate
the end. This pin is placed across the calcaneus when an to provide stability.
ankle-bridging external fixator must be placed. When choosing a location, the pin closest to the
fracture site must be greater than 2 cm away. Pin
(a) placement too close to the fracture could prevent
adequate stabilization.
Care must be taken to avoid placing a pin in the
metaphysis or intra-articular area.
If the fracture is very proximal or distal and there isn’t
adequate tibial shaft to place pins, an articular-spanning
fixator must be placed (see below). The safest area to
place pins into the tibia is anywhere between the
anterior tibial ridge and 60° medially.
Self-drilling tip
Fig. 39.2(a). A self-drilling pin. Pre-drilling the bone prior to placement is not >2 cm
required.
(b)
Proximal Distal
pin sites Fracture
pin sites
Fig. 39.3. Pin site placement in relation to the fracture. Safe placement is
along the anterior aspect of the tibia, with pins placed > 2 cm from fracture.
Avoid the metaphysis.
Make a 4 mm incision over the intended pin sites with a

scalpel and carry down through the periosteum. With the
Central threading self-drilling pin loaded on the drill, place the tip of the pin
directly on the cortex. Apply partial power to the drill until
the pin adequately engages. Then increase power on the drill.
Fig. 39.2(b). A centrally threaded pin is used when placing an ankle-bridging After the tip of the pin passes through the first layer of cortex
external fixator. The pin is placed through the calcaneus with the central and into the medulla, there will be decreased resistance. As
threads engaging the cortex on both sides. the tip engages to the far cortex, the resistance will increase
again. Be sure to allow for several more revolutions of the
pin to be sure that there is secure bicortical purchase.
Without bicortical purchase, the pins can become loose and
Positioning of patient the external fixator can fail to adequately hold reduction.
Placement of external fixators on the lower extremities Repeat the above process with the second pin. When
requires the patient to be in the supine position with the legs judging how far to place the second pin from the first, use a
in a neutral position. 5- or 10-hole pin clamp as your guide. One should place
338
Chapter 39. Orthopedic damage control
the pins as far apart as possible, but still be able to fit them Repeat the above process with the distal pins.
into one clamp. The second pin should be placed parallel to Pin clamps must now be secured around the pins. The
the first. clamp should be placed roughly 1.5 – 2 cm from the skin,
or two finger breadths.
(a)
Tighten all fasteners with a full hand torque while applying
a counter-torque to prevent damage to the fixator
hardware.
(a)
1.5 – 2 cm
Fig. 39.4(a). Drilling the pin into the tibia. It is important that the pin has a
bicortical purchase for maximum stability.
(b)
Fig. 39.5(a). Pin clamp placement. The 5-hole pin clamps used here have
30 degree angled posts. Pin clamps allow for placement of different angled
posts, pointing in any direction. The clamp should be placed approximately
1.5 – 2 cm from the skin/soft tissue. Two finger breadths is a good way to judge
adequate placement.
(b)
Fig. 39.4(b). Placement of the second pin. The pin should be placed parallel
to the first, with the largest distance between the two pins allowed by the
pin clamp.
(c)
Fig. 39.5(b). Tighten all bolts with full torque while applying counter-torque
to prevent damage to the fixator hardware.
Fig. 39.4(c). Repeat the previous step distal to the fracture site.
339
Attach rod-to-rod couplers to the posts, one on each side of external fixator must be placed. The proximal pins are
the clamp. The optimal location is mid post. placed in the tibia as described above. For the distal pin, a
calcaneal pin must be placed. An incision is made over the
medial aspect of the center of the calcaneus.
Using a centrally threaded pin, drill the pin medial to
lateral. Care must be taken to avoid the posterior tibial
artery. This should be inserted until the threads have a
bicortical purchase in both sides of the calcaneus.
(a)
Rod-to-rod couplers
Fig. 39.6. Applying the couplers to the angled posts. They should be placed
near mid post to provide better stability.
At least two connecting rods should be placed parallel to

the long bone, preferably one medial and one lateral. When
placing the connecting rods, a second person should pull
the limb out to length and reduce the fracture. With the
fracture reduced, the rod-to-rod couplers should be
tightened, thus securing the limb in place. Fig. 39.8(a). Incision for the distal pin is placed over the medial calcaneus.
(b)
Carbon connecting
rods
Posterior tibial
artery
Fig. 39.7. Final hardware apparatus after insertion of the connecting rods and
tightening of all fasteners.
Fig. 39.8(b). Take care to avoid injury to the posterior tibial artery.
Distal tibia and fibula fracture/ankle Semicircle representing tibial artery needs to be moved clockwise to run along
posterior portion of medical malleolus from superior to inferior.
instability
In the event that a tibial fracture is too distal to allow for
pin placement above the metaphysis, an ankle-bridging
340
(a) (b)
Pin-to-rod
coupler
Fig. 39.9(b). For the single pin, a pin-to-rod coupler is used.
Fig. 39.9(a). The centrally threaded pin in place, with the threads engaged in
the cortex on both sides of the calcaneus.
Mid-shaft femur fractures

When stabilizing a mid shaft femur fracture, the same
Since a single pin is used, a pin-to-rod coupler must be principles apply as to a tibial fracture. Pins should be
used. One should be placed on each side of the foot. placed no closer to the fracture than 2 cm. The safest
The connecting rods should be placed in the same fashion approach to the femur is laterally.
as for a mid shaft tibia fracture.
If there is concern that the patient could develop skin
breakdown over the ankle, a posterior semi-circular
connecting rod could be placed.
(b)
(a)
Fig. 39.10(b). A semi-circular rod can be placed posteriorly to elevate the

Fig. 39.10(a). The distal fixation hardware in place with bilateral
ankle off the bed, thus preventing a potential pressure sore.
connecting rods.
341
(b)
Pin sites
Fig. 39.11. Pin site selection for a mid shaft femur fracture. Safe placement is
from the lateral approach.
Fig. 39.13(b). Both pin clamps in place with attached post-to-rod couplers.
(c)
Fig. 39.12. Fixation pins in place in the femur.
Pin clamp selection is the same as for the tibia. Be sure that Fig. 39.13(c). The final femur external fixation hardware with connecting rods
they are two finger breadths away from the skin. in place.
Angled or straight posts can be used.
(a)
Fig. 39.13(a). Pin clamp with angled posts being placed two finger breadths Fig. 39.14. Proximal and distal pin sites for treatment of distal femur/proximal
from the skin. tibia fractures. For the proximal pins, the lateral approach is safest.
342
(a) (b)
Fig. 39.15(a). Proximal pins in place. Fig. 39.15(b). Distal pin placement into the tibia. As with a tibia fracture, the
safe pin approach is along the anterior surface.
(c)
As with the tibia, the femur should be pulled to length
before completely tightening the fasteners on the
connecting rods.
Distal femur/proximal tibia

For fractures involving the distal femur or proximal tibia
that preclude safe pin placement outside of the knee joint, a
knee-spanning fixator may be required. Pin site selection
criteria on the femur are the same as for a mid shaft femur
fracture. Since the entire weight of the lower leg will be
resting on the knee-spanning apparatus, further spaced pin
placement in the tibia may be necessary.
Fig. 39.15(c). Distal pins are in place. Since the length of the external fixator is
significantly longer when bridging the knee, placing the distal pins further apart
will provide an increase in stability.
(b)
(a)
Fig. 39.16(b). The knee-spanning external fixator in place. Only one spanning
rod is present in the picture. If the surgeon feels that there isn’t enough stability,
Fig. 39.16(a). Pin-to-rod couplers in place. Because the pins were placed far a second spanning bar could be placed.
apart to increase stability, pin clamps will likely not be long enough to use.
Couplers are necessary for connecting hardware.
343
“Floating knee” types of fractures. Communication between all members of

the team is critical to achieving optimal outcomes in these
A special case could arise where there is both a distal femur multisystem injuries.
fracture and proximal tibia fracture. A knee-spanning
As with any reduction of a comminuted fracture, after
external fixator would provide stability to the lower leg, but
application of external fixation hardware, a postreduction
the bony structures of the knee joint would still be unstable.
neurovascular check must be performed and documented
This would be an instance where a long-leg splint would
in the record.
need to be placed in addition to the knee-spanning external
fixator. Pin placement in relation to the fracture site is very
important. Pins placed too close to the site will not provide
adequate stability to reduce and stabilize long bone
Pin care fractures. When placing the two pins, try to place the pins
External fixator pin sites can be a focus of infection. The far apart but still able to fit into the pin clamp.
pin sites should be cleaned daily with chlorhexidine When placing an ankle bridging external fixator, attention
gluconate and dressed with iodine-soaked gauze. must be paid to anatomy to avoid neurovascular structures,
such as the posterior tibial artery.
Tips and pitfalls All screws and bolts must be tightened to full torque to
Not every patient who suffers a long bone fracture will prevent equipment slippage and loss of fracture reduction.
require a damage control intervention. Knowing when to Counter-torque must be held on the hardware to prevent
apply the principles of early definitive fixation vs. DCO damage during tightening.
requires clinical knowledge and skill in managing these
344
Index
Figures and illustrations are indicated in bold typeface
abdominal aorta surgical technique, 315, 315, postoperative care, 239 surgical principles, 115
anatomy of, 240, 240–241 317, 318, 320, 322 surgical principles, 238 surgical technique, 116,
complications, 256 amputations (upper extremity) surgical technique, 238 116–123, 117, 118, 120, 122,
instruments, 242 anatomy of, 294, 294 bleeding. See also hemorrhage 123
patient positioning, 242 complications, 302 abdominal injuries, 169, thoracic vessels, 126–139
surgical principles, 242 instruments, 295, 295, 296 169–171, 170, 173, 179 cardiac massage, 22, 24
surgical technique, 242–256, surgical principles, 294–295 and EDH/SDH, 36 carotid artery
243, 245, 248, 250, 252, 253, surgical technique, 295–301, and laryngotracheal injuries, anatomy of, 53, 53, 54
254, 255 296, 297, 300, 301 100 complications, 68
abdominal injuries anastomosis cardiac repair, 120, 120–122, instruments, 56
aorta, 240–256 esophageal, 152, 161 122 patient positioning, 56
DC in, 172–179 intestinal, 171, 185 kidney, 229, 229–231, 231 surgical principles, 55–56
duodenum, 189–197 popliteal artery, 312–313 liver, 203, 203–207, 205 surgical technique, 56–68, 57,
gastrointestinal tract, 180–188 ureter, 235–236 operating room supply, 3 60, 65, 66, 135, 135–136
general principles, 165–171 angioembolization (vertebral spleen, 212 catheter
iliac, 257–261 artery), 93 blunt trauma EVD, 30, 34
inferior vena cava, 262–272 aorta abdominal, 184, 204, 262 ICP, 29–34
liver, 198–208 abdominal, 240–256 and EDH/SDH, 35 celiac artery, 251
pancreas, 219–227 cross-clamping, 27 arterial, 66, 135, 137, 254, 308 cerebral spinal fluid (CSF),
spleen, 209–218 thoracotomy cross-clamping, cardiac rupture, 115 32–33
urological, 228–239 26 lung, 142 cervical esophagus
above-knee amputation (AKA), artery parenchymal damage, 205 anatomy of, 101
315, 315, 317, 318 brachial, 281–287 retroperitoneal hematoma, complications, 101–105
ABThera technique, 175–179, carotid, 53–68, 135–136 242, 264 instruments, 101
177 celiac, 251 spleen, 211 patient positioning, 101
acute epidural hematomas femoral, 303–306 Bogota bag technique, 174 surgical principles, 101
(EDH) mesenteric, 252–253, 256 brachial artery surgical technique, 102, 102,
surgical principles, 35–38, 36 renal, 253–255 anatomy of, 281, 281 103, 104
surgical technique, 41, 41–45, subclavian, 72–81 complications, 287 chest trauma
44 axillary artery, 83–87 instruments, 282 cardiac injuries, 115–125
adductor canal, 303, 303 axillary vessels patient positioning, 282 DC in, 172
air embolism complications, 86–87 surgical principles, 282 general operation principles,
arrhythmias, 26 instruments, 84 surgical technique, 283, 107–114
in cardiac injuries, 115 patient positioning, 84, 86 283–286, 285, 286 clamshell incision
lung injuries, 149 surgical anatomy, 83 Burr holes, 41, 41–43, 42 general chest operation, 108,
neck trauma, 52 surgical principles, 84 113, 114
thoracic vessels, 135, 139 surgical technique, 84, 84–86, cardiac arrest. See also heart lung injuries, 143
airway management 86 failure thoracic vessel, 130
cricothyrotomy, 6 air embolism, 26 clavicular incision
neck trauma, 52 Barker’s vacuum technique, 174, pharmacological treatment of, general neck trauma, 52
amputations (lower extremity) 179 23 subclavian vessels, 72–77, 73,
anatomy of, 314 below-knee amputation, cardiac defibrillation 75
complications, 319, 321 319–322, 320, 322 (thoracotomy), 24 supra, 80
instruments, 315 billary tract injuries, 207 cardiac injuries with median sternotomy, 78
patient positioning, 315 bladder anatomy of, 115, 115 collar incision
postoperative care, 322 anatomy of, 229 instruments, 116 general neck trauma, 51, 51
surgical principles, 314 complications, 239 patient positioning, 116 trachea and larynx, 96, 96
345
Index
colon cervical, 101–105 surgical principles, 107 esophageal, 153, 153, 154
anatomy of, 185 complications, 161 surgical technique, 108, femoral artery, 304–305, 305
complications, 187 instruments, 152 108–113, 110, 111, 113, 114 foot fasciotomy, 333
surgical principles, 185–187, patient positioning, 152–153, general gastrointestinal operation general abdominal operation,
186 153 instruments, 180 167, 167–169, 169
common bile duct injuries surgical principles, 152, 181, 183 patient positioning, 180 general chest operation, 108,
(CBD), 207 surgical technique, 153, 153, surgical technique, 180 108–113, 110, 111, 113, 114
compartment pressure 154, 156, 158 gluteal compartment fasciotomy, gluteal compartment
measurement technique, EVD. See external ventricular 325–326 fasciotomy, 325, 325–326
324, 324–325 drain guillotine amputation (below iliac injuries, 258
compartment syndrome external ventricular drain (EVD), knee), 322 IVC, 263
and axillary vessels, 87 30, 34 gunshot wounds kidney, 229
upper extremity fasciotomy, cardiac injuries, 115 liver, 201, 201, 202
293 fasciotomies (lower extremity) liver, 204 lower leg fasciotomy, 329, 329,
complications anatomy of, 323 mediastinal artery, 135 330, 331
abdominal DC, 179 complications, 334–335 to neck, 48 lung injuries, 143
cardiac injuries, 118, 120, 125 instruments, 324 neck trauma, 50, 50, 51, 52
gastrointestinal tract, 183 surgical principles, 323 hand fasciotomies, 290, 292 pancreatic, 220
general neck trauma, 52 surgical technique, 324, head trauma procedures popliteal artery, 309, 309–310
thoracostomy tube, 17 324–325, 325, 327, 327, 328, hemotomas, 35–45 spleen, 212
craniectomy incision, 39–40, 40 331 intracranial pressure subclavian vessels, 72–81, 73,
cricothyrotomy fasciotomies (upper extremity) monitoring, 29–34 75, 78, 81
anatomy of, 5, 5 anatomy of, 288 heart failure, 149, See also cardiac thigh fasciotomy, 326, 328
difficulties with, 11 complications, 293 arrest thoracic vessels, 129–130
instruments, 6, 6 instruments, 289 hematomas thoracotomy, 19, 19–21, 21, 27
patient positioning, 7 patient positioning, 289 abdominal aorta, 242 trachea and larynx, 96, 96, 98
surgical principles, 6 surgical principles, 288 abdominal injuries, 169, upper extremity, 289–291, 290
surgical technique, 7–11, 8, 9, surgical technique, 289, 291, 169–171, 170 vertebral artery, 89, 89, 91, 92
10 292 duodenum, 196 indications
femoral artery retroperitoneal, 264 DC, 172
damage control (DC) anatomy of, 303, 303 hematomas (cranial) enteric contamination, 258
abdominal, 172–179, 173, 174, complications, 306 anatomy of, 35, 35 for EDH/SDH surgery, 34, 38
175, 177 patient positioning, 304 instruments, 39 pelvic, 274
extremities, 172 surgical principles, 304 patient positioning, 39 thoracotomy, 18
orthopedic, 337–344 surgical technique, 304–306, problems, 41, 43 upper extremity operation, 282
pelvic, 275, 275–280, 278, 279 305 surgical principles, 35–38, 36 inferior mesenteric artery, 256
surgical principles, 172 femoral triangle, 303 surgical technique, 40, 41, 44, inferior vena cava (IVC)
vascular trauma, 172 femur fracture, 341–343, 342 45 anatomy of, 262
DC, See damage control fibula fracture, 340 hemorrhage. See also bleeding complications, 272
diaphram floating knee, 344 IVC, 266, 266–270, 267, 269 instruments, 263
anatomy of, 162 foot fasciotomy, 333 pelvic, 273–280 patient positioning, 263
complications, 164 forearm fasciotomies, 290, 292 hilar occlusion, 26 surgical principles, 262–263
instruments, 162 fractures hilar twist, 26 surgical technique, 263, 263,
surgical principles, 162 femur, 340, 340, 342, 342 264, 265, 266, 267, 269, 271
surgical technique, 162–164, management of, 338, 338–344, ICP. See intracranial pressure innominate artery, 135, 135–136
163, 164 339, 342 monitoring intestines
distal femur fracture, 342, 343 pelvic, 187–188, 273–274 iliac injuries small, 183–185, 184, 185
distal tibia fracture, 340 rib, 107, 114, 153 anatomy of, 257, 257 spillage control, 174
duodenum skull, 36–37 complications, 261 intracranial pressure monitoring
anatomy of, 189–190 spinal, 88 instruments, 258 (ICP)
complications, 197 tibia, 338, 338–340, 339, 340 patient positioning, 258 anatomy of, 29
instruments, 191 surgical principles, 257–258 and SDH/EDH, 45
patient positioning, 191 gallbladder injuries, 207 surgical technique, 258, instruments, 30
surgical principles, 190–191 general abdominal operation 258–261, 261 patient positioning, 31
surgical technique, 191, anatomy of, 165, 165 incision problems, 34
191–197, 194, 196 complications, 171 abdominal aorta, 242 surgical principles, 29
instruments, 167 above-elbow amputation, surgical technique, 31, 31, 32
EDH. See acute epidural patient positioning, 166 295–296, 296, 297 types of, 30
hematomas surgical principles, 165–166 axillary vessels, 84 intraparenchymal intracranial
epicardial pacing, 24, 24–27 surgical technique, 167, below-elbow amputation, 299 pressure monitoring (ICP),
epidural intracranial pressure 167–171, 169, 170 brachial artery, 283, 283 30, 33
monitoring (ICP), 30, 34 general chest operation cardiac injuries, 116, 116–123, intraventricular intracranial
esophagus anatomy of, 107, 107 117, 118, 122, 123 pressure monitoring (ICP),
anatomy of, 150–152, 151 complications, 114 carotid artery, 56 30, 31, 32
anesthesia, 152 patient positioning, 108, 108 duodenum, 191 IVC. See inferior vena cava
346
Index
kidney lung injuries, 143 pediatrics SDH. See subdural hematomas

anatomy of, 228, 228 thoracic vessel, 129 anastomosis, 171 sepsis, 161, 179, 234
complications, 234 mediastinal artery injuries, cricothyrotomy, 6, 11 small intestine
patient positioning, 229 135–139, 136, 137 EDH, 38 anatomy of, 183–184
postoperative care, 234 mediastinal vein injuries, 135 thoracostomy, 13 complications, 185
surgical principles, 229 mesenteric artery (inferior and pelvis surgical principles, 184, 185
surgical technique, 229, superior), 252, 252–253, anatomy of, 273, 273 spleen
229–233, 231, 234 253, 256 blood control, 274 anatomy of, 209–211, 210
mesh complications, 280 complications, 218
laparoscopy (diaphragm), abdominal, 173 instruments, 275 instruments, 212
162–164, 163 facial defects, 179 patient positioning, 275 patient positioning, 212
laparotomy liver, 205 surgical principles, 274 surgical principles, 211
abdominal, 167, 167–169, 169, spleen, 213 surgical technique, 275, 275, surgical technique, 212, 212,
242 278, 279 213, 215, 216
duodenum, 191 neck trauma percutaneous cricothyrotomy, splenectomy
gastrointestinal tract, 180 axillary vessels, 83–87 7–8, 8 partial, 215, 215, 216
iliac injuries, 258 carotid artery, 53–68 pericardiotomy incision total, 213, 213–215
IVC, 263 cervical esophagus, 101–105 (cardiac), 118, 118–120 splenorrhaphy, 215, 215–216
kidney, 229 general operation principles, pitfalls. See complications stabbing wounds
liver, 201, 202 47–52 pneumonectomy, 147, 148 cardiac injuries, 115
pancreatic, 220 instruments, 50 pneumonorrhaphy, 143 mediastinal artery, 135
larynx patient positioning, 49 popliteal artery to neck, 48
anatomy of, 94, 94 subclavian vessels, 69–82 anatomy of, 307 sternocleidomastoid incision
complications, 100 surgical anatomy, 47–48 instruments, 308 general neck trauma, 50, 51
instruments, 95 surgical principles, 48, patient positioning, 308 trachea and larynx, 97–99,
patient positioning, 95 48–49 surgical principles, 308 98
surgical principles, 95 surgical technique, 50, 50, 51, surgical technique, 309, vertebral artery, 91, 91–92,
surgical technique, 97, 99 52 309–313, 311, 312, 312 92
Lazy S incision, 290–291, 291 trachea and larynx, 94–100 posterolateral thoracotomy stomach
left thoracotomy incision vertebral artery, 88–93 esophageal, 153, 154 anatomy of, 180–181
(cardiac injuries), 118 negative pressure therapies general chest operation, 108, surgical principles, 181
liver (NPT) 113–114, 114 subarachnoid bolt, 30, 33
anatomy of, 198, 198–199, abdominal, 174, 174, 175, 177 thoracic vessel, 130 subclavian vessels
199 lower extremity fasciotomy, postoperative care anatomy of, 69, 69, 70, 72
complications, 208 334 bladder, 239 complications, 82
instruments, 200 upper extremity fasciotomy, kidney, 234 instruments, 72
patient positioning, 200 293 lower extremity amputations, patient positioning, 72
surgical principles, 200 nephrectomy, 232–233, 234 322 surgical principles, 72
surgical technique, 201, lower extremity fasciotomy, surgical technique, 72–81, 73,
201, 202, 203, 204, open cricothyrotomy, 9, 9–10, 334, 334 75, 78, 81, 137
205, 206 10 orthopedics, 344 subdural hematomas (SDH)
lower extremity injuries operating room ureter, 237 surgical principles, 35–38,
amputations, 314–322 blood supply for, 3 problems. See complications 36
fasciotomies, 323–335 composition of, 1, 2 proximal tibia fracture, 342, surgical technique, 41, 41–45,
femoral artery, 303–306 equipment, 2 343 44
lower leg fasciotomy, 329, 329, set-up, 2 pyloric injuries, 183 superior mesenteric artery, 252,
330, 331 temperature of, 2 252–253, 253
lung injuries orthopedic damage control rectum supraceliac aortic control, 243,
anatomy of, 140, 140 (DCO) anatomy of, 187 243, 245, 248
anesthesia, 143 complications, 344 complications, 187–188, 188 supraclavicular incision
complications, 149 instruments, 337, 337–338, surgical principles, 187 subclavian vessels, 80, 80
diaphragm, 162–164 338 renal artery, 253–255, 254, vertebral artery, 89, 91
instruments, 143 patient positioning, 338 255 supramesocolic aorta, 248–251,
patient positioning, 143 surgical principles, 337 resection 249
surgical principles, 142–143 surgical technique, 338, colon, 187
surgical technique, 143, 338–344, 339, 342 liver, 205–207, 206 temperature (operating room), 2
143–149, 144, 146, 148 lung, 145, 146 thigh fasciotomy, 327, 327,
thoracic esophagus, 150–161 pancreas pancreatic, 226, 226 328
anatomy of, 219, 220 small intestine, 185 thoracic vessels
median sternotomy incision complications, 227 resuscitative procedures anatomy of, 126, 126–128,
cardiac injuries, 116, 117, 123, instruments, 220 cricothyrotomy, 5–11 128
123 patient positioning, 220 thoracostomy tube, 12–17 complications, 139
general chest operation, 108, surgical principles, 220 thoracotomy, 18–27 instruments, 129
108–110, 110, 114 surgical technique, 220–227, retrohepatic inferior vena cava, patient positioning, 129
liver, 202 221, 223, 224, 226 270–272, 271 surgical principles, 129
347
Index
thoracic vessels (cont.) surgical principles, 18 laryngotracheal, 99 surgical technique, 235, 235,
surgical technique, 129, 129, surgical technique, 19, 19–27, tractotomy 236, 238
130, 131, 133, 136, 137 21, 24 liver, 204 urological trauma, 228–239
thoracostomy tube thoracotomy incision lung, 144
autotransfusion in, 17 abdominal injuries, 242 trap door incision (subclavian vacuum-assisted closure
difficulties with, 17 general chest operation, 108, vessels), 81, 94–100 technique (VAC), 176
insertion site, 12 110–112, 111, 114 vascular trauma
patient positioning, 12 lung injuries, 143 ultrasound, 82 abdominal aorta, 240, 240
removal, 17 tibia fracture, 338, 338–340, 339, upper arm fasciotomy, 289 damage control, 172
surgical principles, 12 340 upper extremities DC in, 172
surgical technique, 12–17, 14, trachea amputations, 294–302 popliteal artery, 308
15 anatomy of, 94 brachial artery injury, retroperitoneum, 165, 165
thoracotomy complications, 100, 105 281–287 vertebral artery
anatomy of, 18 instruments, 95 fasciotomies, 288–293 complications, 93
instruments, 19 patient positioning, 95 ureter instruments, 89
patient positioning, 19 surgical principles, 95 anatomy of, 228 patient positioning, 89
posterolateral, 108, 113–114, surgical technique, 96, 96, 98 complications, 236 surgical anatomy, 88, 88
114, 130, 153, 154 tracheostomy postoperative care, 237 surgical principles, 88
problems, 27 and cricothyrotomy, 6 surgical principles, 234–235 surgical technique, 89, 89, 91, 92
348

Atlas of Surgical Techniques in Trauma

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Atlas of Surgical Techniques in Trauma

Atlas of Surgical Techniques

Kenji Inaba MD MSc FACS FRCSC

George Velmahos MD PhD FACS

Cambridge University Press is part of the University of Cambridge.

Every effort has been made in preparing this book to provide

To those who inspired me and those who allowed me to become a trauma

Section 1 – Operating Room General Conduct 11. Vertebral artery injuries 88

5. Insertion of intracranial pressure monitoring 17. Lung injuries 140

6. Evacuation of acute epidural and subdural 18. Thoracic esophagus 150

23. Duodenum 189 33. Upper extremity fasciotomies 288

Section 7 – Pelvis Section 10 – Orthopedic Damage

Section 8 – Upper Extremities

Howard Belzberg Peter Hammer

Nicholas Nash Peep Talving

Trauma operating room

1 Kenji Inaba and Lisa L. Schlitzkus

Operating room other ORs, blood bank, and laboratory should be

Fig. 1.1. Hybrid operating room setup.

Fig. 1.2. Emergency release blood products

2 Peep Talving and Rondi Gelbard

Surgical anatomy  The vocal cords are attached to the internal

Cricothyroid membrane Cricoid cartilage

(a) insufflation should be considered. For patients with suspected

Fig. 2.2(b). Photograph demonstrating the four-finger technique for

Patient positioning Technique

Open cricothyrotomy exposing the cricothyroid membrane. Senn retractors can

 With the dominant hand, insert the cricothyrotomy tube (e)

Thoracostomy tube insertion

3 Demetrios Demetriades and Lisa L. Schlitzkus

General principles (a)

 Strict antiseptic precautions and personal protective

Site of tube insertion

(c) clamp is released and withdrawn, while the tube is

Fig. 3.1 (a)–(c). (cont.)

(d) border of the rib to avoid injury to the intercostal vessels,

 Connect tube to an underwater chest drainage collection

(a) (b) (c)

Emergency room resuscitative thoracotomy

4 Demetrios Demetriades and Scott Zakaluzny

Surgical anatomy in the presence of cardiac tamponade or an empty heart

scissors taking care to avoid injury to the underlying

Divided pectoralis major m

Left lower lobe

Left lower lobe

Fig. 4.5(a)–(c). (cont.)

 Any tamponade is then released and cardiac bleeding is

Open cardiac massage

Internal cardiac defibrillation Pharmacological treatment of

 Epicardial pacing wires are usually placed on the upper

Air embolism Hilar occlusion

Fig. 4.11(a)–(c). (cont.)

Fig. 4.11(a)–(c). Cross-clamping of the thoracic aorta. The most accessible

Insertion of intracranial pressure monitoring

Cerebral perfusion pressure (CPP) is a calculated Special surgical instruments

Intraventricular ICP monitor Twist drill

Inject 1% lidocaine with or without epinephrine in the skin

is encountered after three attempts, then an

Fig. 5.8. Insertion of the intraventricular catheter. Insert perpendicular to the

FACE Avoid excessive loss of CSF, as the brain may not

Surgical anatomy The vocal cords are attached to the internal

With the dominant hand, insert the cricothyrotomy tube (e)

Strict antiseptic precautions and personal protective

Connect tube to an underwater chest drainage collection

Any tamponade is then released and cardiac bleeding is

Epicardial pacing wires are usually placed on the upper

EDHs develop when blood collects in the space (b)

Acute SDHs are commonly caused by bleeding from brain

The acute EDH appears as a hyperdense lenticular

Patients with EDH/SDH may present with a wide array of

Surface anatomy Zone I: from the sternal notch to the cricoid

Always place intravenous lines in the arm opposite the (a)