Exploratory Laparotomy in a Hemodynamically Stable Patient for an Abdominal Gunshot Wound

CHAPTER 1

Hi, I'm Dr. Brian Williams. I am an associate professor of trauma and acute care surgery at the University of Chicago Medical Center. I am also the co-director of the surgical intensive care unit, and I'm working on getting a trauma fellowship here, and the case you're about to see is a classic trauma case of a gunshot wound to the abdomen in a hemodynamically stable patient. And the indication for the surgery was he was shot in the belly and he had peritonitis. So we brought him to the OR, and what you will see are the classic steps for an emergent exploratory laparotomy. We'll get into the abdomen, we will check for hemorrhage, major bleeding. We will control the GI spillage and then we will do a thorough exploration, looking for any injury we possibly can and then repair those injuries. So what we found in this patient was that he had a through-and-through gunshot wound to his distal jejunum, the small bowel, as well as a partial-thickness injury to his proximal cecum, which is the beginning of his large bowel. And we repaired those two injuries, went through the exploration several times to make sure we didn't miss anything, and at the end we closed him up, and he did pretty well. We're going to extubate him in the OR, send him to the recovery room and to the regular floor, and he should be able to go home in a few days, assuming that nothing happens in the interim. So I hope you learn a lot from this case, and again, this is a classic trauma case of a gunshot wound to the abdomen in a stable patient.

CHAPTER 2

All right, so we have a gunshot wound to the abdomen. He presented with peritonitis in the ED. This is one of our classic trauma cases. It's a G shot to the abdomen, peritonitis, but he was stable, so therefore he probably does not have a major abdominal vascular injury. Small bowel, colon, some kind of hollow viscous injury is most likely what he has. That's what we're here to do now. Now we make our midline incision - xiphoid to pubis. So what I do is go ahead and - you will grab - I'll grab an Allis, please. So you can take a knife, just go straight down by the umbo. I think we should go on the right side of the umbo that way if you have to do a diverting colostomy, you don't have your incision competing with your stomal appliance. Incision. Now see all this blood here? That's actually a good sign, right? Because bleeding if he was in hemorrhagic shock, you wouldn't see all that. Knife back. You can relax with this now - So Bovie. We have time to go ahead and get hemostasis. Carry the incision down through the subcutaneous tissue with your Bovie, getting hemostasis on the way down. Can we have a DeBakey, please Christina? All right, slow easy strokes. Control the Bovie, control the energy. Pause for a second. Now you each pull across from each other. That way, you're going down the midline. You will see the tissue divided between the two of you. Here you go, Dr. Suah. What number resident are you? Do you mean what lab - what year? Yes. PGY3. PGY3? You been hiding out in the lab? Yep. Mm - mm, mm, mm - your lucky night, huh? Lucky night for you. Love it. We got time. Stop all this bleeding, take care of that. Yep. Good. The biggest part of the abdomen is right above the umbo, so we're going to, at some point, we're going to get us a little window right there and pop in, but go ahead and get all this so you're not - dug yourself into a hole. Do you want the Bovie turned up a little bit? See when you guys are pulling apart from each other? See how it splits right down the middle? Yeah. He's got a lot of sub-q tissue there. Redundant tissue. And try to stay in the middle because if you pull it to one side, that's how you get off midline of the fascia. You know, there's no reason why you should be off the midline of the fascia in this case - or any case. Especially this case. All right, now get up here on the umbo. Now we're going to - so let go. See where the anatomy is. Right around here, that's the weakest part of the abdomen, right? You get down the midline there, you can make a little hole. You should be able to pop right into the peritoneum. And that's a great move you want to do if the patient's crashing, so you can get into the abdomen pretty quickly, okay. But you might as well practice it now while your patient is stable. On the midline. Look for those fibers, crossing. Want me to open it now, or or extend it a little bit higher? So, look where you are. So you're here. You want to be right around there. Okay. And I want you to show me that you're in the midline before you open up anything. Now take a pause here for a second. You can do like this, and you can pull it apart like that. You're getting closer. 14? So, hemoglobin is 14, which is good. With a base excess? So hemoglobin of 14 is good, that means he's not bleeding to death, but a... (mumbles) He's a little bit acidotic. Oh, see that's good, see, you're right down there. I want you to pop in. You think? All right, let me - I don't believe you. I mean, I believe you. You think I'm preperitoneal still? Okay, I like you. We have a layer of preperitoneal fat. I like you, I don't trust you. One of my attendings used to tell me that all the time. All right, good. So now let me show you something here real quick, all right? This should take three or four strokes to go down all this, right? One is getting all sub-q off the top, and the second is going through the fascia. You're going to pinch to make sure what you have between your fingertips is not bowel, all right? Go through that. And then you're going to kind of keep doing that maneuver all the way up. Fascia. Pinch. Not bowel. All right, do that all the way cephalad and caudad. So right now we don't see any blood pouring out of this hole here. Don't see any obvious stool or succus as of yet. Those are all pretty good signs that he does not have life-threatening injury, but we never - never get complacent. Okay? All right, let's get this open so we get some exposure. I'm going to step back so the student can take a look here. So her abdomen's open, we don't see any major bleeding. No major bowel contents. I'll use a Balfour, please. All right, are you high? Can you feel the xiphoid? How high up are you? Okay, so let's get this open here. Now be careful, see how you're distorting us off midline, I don't want you to get off midline with your fascial incision. See, you're pulling us across this way, it's easy to get yourself to one side or the other by doing that. Look for the fibers crossing like this, right? So they're facing that way. So we have the incision opened as far cephalad, means toward the head. Now we're working caudad, towards the feet. Now you want to work your incision this way, okay? Go from known to unknown. Known to unknown. You can put your hand there and see where you can feel the pelvis, how much more distance do you have? Mmm, to about right there. Okay. Pubis stuff. What I meant - that'll be the caudad extent of our incision. Be careful burying the Bovie, the bowel can sneak up on you. So you see all this subcutaneous fat he has here. That's how much you have intraperitoneal as well. That's good. Baby Rich, please. Thank you. Thanks.

CHAPTER 3

All right, let me switch with you again, let's see what we got up in here. All right, so we're taking a quick look here, still no blood welling up Vegetable. We found some food though, vegetable matter. See that on the camera? That means there's a hole somewhere in his bowel, all right? So we put the Balfour in please. Go ahead and get this. Don't catch your glove, that's easy to do. That's why I asked you to do it because I always do it. So pad your pressure points here with that. Get this all the way open, yep. All right so we have - through-and-through gunshot wound to small bowel here. So principles of ex lap penetrating traumas - control the hemorrhage, control the bleed - or control the GI spillage. Just do two of those. Can I have another one, please? There is no major hemorrhage at this point, but we see an obvious hole, so let's go ahead and control that. Now what can kill you? Retroperitoneal... A retroperitoneal bleed, so we're looking at our three zones, right? So zone one is periaortic, zone two is your perinephric, and zone three is in your pelvis. So systematically how do you get to zone one first? We can pull down the stomach. Liver up, stomach down. Is the OG in? Putting it in now. Okay. The stomach's just a little distended, but I don't see anything. Right, so this is quick so we look, no hematoma there, boom, move on to the - so that's supramesocolic, how do you get to the inframesocolic zone one? Lift up our transverse colon here. I don't see any bulging... So nothing there. So if there was a zone one hematoma, if it's penetrating or blunt, you'd explore that, that's a - aortic injury or and IVC injury, so that cannot wait. So next is zone two - perinephric. So we can look on the right side first, so Harry will move everything over to his side. But no hematoma, right? We're looking for life-threatening stuff, right? Life threatening stuff. We don't see that... Kidney feels fine. Next one, that's right, go to the left. Nothing there, good, big Rich, please. So lift everything up. This is all methodical and quick. So zone three is your pelvis, this will be iliac injuries. Left and right look fine. So we see no zone one, two, or three retroperitoneal hematomas. So far we have this one injury, well two injuries, one segment of the bowel. So now what do we do next? So now we can run the bowel, but we can also take a feel just for practice of the solid organs. Oh no, it's not practice, we do this for every single, yeah - so you're right, feel above liver and the diaphragm as well. So you're feeling for liver injuries and... So... You want us to take the falci, or not necessary? That's a good question, yeah. So here's your - we'll leave this here, here's your falciform ligament. If you need to get better exposure up top, we can take that down, but we'll leave that for now. I don't think we need to take that down. So again, we've reviewed our steps for penetrating abdominal trauma, exploration - get in, first thing we do is control the bleeding, you control the GI spillage. There was no major bleeding to control. We've gone through a GI spillage, which you have here. That's under control, operation's under control. We look for retroperitoneal hematomas because those may need to be dealt with first. We looked at zone one. Stomach down, liver up. We looked at inframesocolic, colon up on the chest, down to the base, nothing there. If there was a hematoma there, that would require immediate exploration, that's an aortic injury or IVC injury. Zone two, also known as perinephric hematomas. Right side, saw nothing, but we see this little hole there. Left side, nothing. So we're looking for bulges there, these hematomas. Bend down to the pelvis. Big Rich again, please. These will be your iliacs, and nothing there. So now we got plenty of time to take care of everything, right? Everything's under control. So now we're going to run the bowel - run the bowel. So we start at the ligament of Treitz. The ligament of Treitz - that's also known as the suspensory ligament of the duodenum. So transverse colon here - goes up on the chest, go down to the base of the transverse mesocolon, and you tug there - not coming any further. That's your ligament of Treitz. That's the beginning of your jejunum. We're here, so you grab your segment here, Dr. Suah. Two hands. So between the two of us, this should be spread out into a big old "C." We should see all the way down to the base of the mesocolon. So we'll both flip it over, both sides, you can see on both sides, so we're looking all the way down. And we're working together, so I should not get ahead of you, and vice versa. So whenever we're handing this off, it stays in a big "C," so as we're moving forward also, we're milking the bowel. Slowly, to make sure we don't miss any small punctate holes. Okay. So we're looking for holes in the bowel, looking for hematomas in the mesentery, or injuries in the mesentery, all the way down to the base. So it needs to be spread out. Okay? And we're milking it, right? See that maneuver? Got that? Yep. Back to the beginning. It's all you now. This is called running the bowel. Okay. We're looking for holes in the bowel, holes in the mesentery, vascular injuries here that would lead to devascularized bowel. Two-person maneuver - keep that thing fanned out. Oh, that's beautiful - I love this anatomy. Milking as you go - yep. Mm hmm. Now see how you're bunching up there? Work together here, stay together, it's like a dance. We're going from proximal to distal, fanning it out, looking all the way down to the base, yep. So it's flip, flip, milk - flip, milk, flip, milk - staying together. The caliper's changing - getting down to the ileum. Fanning it out. Get it all fanned, so - yeah. Stay together. So we have the one segment - our bullet holes need to add up. So it should be even numbers, so we have two here. Good so far. All right, coming down to terminal ileum. Oh, here's some good stuff. Let's talk about some anatomy here. Can you see this? Yeah. That's your appendix. When you get appendicitis, that comes out. Here is your fat pad of Treves. So if you're doing a laparoscopic appendectomy, you look for this, and that always points to appendix. So it's here. Terminal ileum. Here's your cecum. Appendix. Now we're getting into the large bowel. Looks like a little bit of something there as well. Mm hmm. So, you see all that? Yep. Oh, get a picture of that. That's beautiful. Okay. Mm. I can't tell if it's a little rent from it, like... Yep. Well we're going to find out. He may be getting an ileocecectomy - we'll decide here in a minute. Okay. I think so - right colon, here. So there's a hole there, right? Yeah, that was the one I think you... And we saw the bullet back here on the x-ray. So the bullet's back there somewhere. We don't take out bullets like they do in the movies. You cause more damage, going after them. If they're laying there, you pull them out, but you never go digging for them. All right. We should identify the ureters. Okay. I have the... Colon. Mm hmm. The hepatic flexure's coming up, right? So we're going to end up mobilizing this right colon. We're just - We'll do a quick exploration right now. Now for the transverse colon, you will have penetrating injuries that will hide here at the base because - you see all this fat here? Mm hmm. So you have to be really methodical about exploring that, and we'll get into the lesser sac - it's already open for us, huh? That's nice. Okay, so we'll do this a couple times, so - continue. Mm hmm. So we've already run the small bowel, we found two holes there - looked like distal jejunum. There's a contusion on the cecum. With that hole on the retroperitoneum back there, and that's consistent with the potential bullet tract. Big Rich, please. Now we're running the left colon. I'll hold this for you, so you can help her. That's just the small bowel that's in the way of it. All right, we need some GIA staplers. Do you have the LigaSure for... And LigaSure also, please. What did you say? Fat one. That one looks fine. Can we have the suction, please? Now let's take a look down there in the pelvis. That's why rectal cancers hurt so much, got that small... GIA 60 or 80? Uh - 60. 60. All right, let's go ahead and get this segment out. Okay.

CHAPTER 4

So we'll take care of this, this is out of the way, still got to lift up the right colon, look in the Lester sack. I'll take the stapler. Three. Stapler, please. All right, you watching? You get to do the next one. Okay. Watch him close. Thank you. So, we're going to excise this area of the small bowel where there's a gunshot wound. Or two of them. Another load, please. Suture scissors. Cut on the knot, please. On the knot? Yep. All right, we'll let our student do this one, and you're going to get to do the anastomosis. Great, okay. Are you left handed or right handed? Left handed. That explains it. My wife's left handed, so I won't hold it against you. Okay, that slides in there. Okay. Now when you look at this, you want to make sure that - when your staples are done, it's going to go all the way through, all right? Yep. You don't want it too far in the butt because you'll miss a few staples there. Okay. Too far at the end, you'll miss some staples on the far end, so you want to be right in the middle there. Then you should put your support here. The stapler's designed to help us with a mechanical advantage. So that fires your staples pushing forward. Good - pulling back divides it. Press that black button - opens. Then you pass that back to your scrub. Nice job. Thank you. Good job. Now this is mesentery, this is blood flow, to this bowel, so we have to control the bleeding across here. So our LigaSure will take this off and give us hemostasis. All right. Specimen. Specimen: small bowel. Thank you. You're welcome. Anytime you take anything out of the body, we make sure we label it appropriately, and send it to pathology.

All right, so now we have our two ends here. This is probably the proximal end, and the distal end - we'll do our anastomosis. So we're constructing a side-to-side, functional end-to-end anastomosis. Yeah, that's what I want. So side-to-side, our two ends are coming side-to-side, and once it's done, it'll be a functional end-to-end, which you will see shortly. And let's get us some of this to catch any. So these stay sutures are meant to take off tension from the new anastomosis. When you're passing sharps, say it out loud: "needle back." Make that a habit - assume nothing. Take care of your team. Ooh. A little bit smaller, kind of curve it up towards this way, yep. Mm hmm. Are these - Are those Mayos or suture scissors? Yeah, curved Mayos. So let me just hug the babcock with this. Okay. Let me have our stapler, please? So this hole's a bit bigger than we need here, but we'll make that work with our staple. And then you want the antimesenteric side. So we're not - so the pink side, not the yellow side - to come together. We can align them once we get the staplers. You're doing good - doing well. All right, so we have a staple inside each limb. Mm hmm. We align the antimesenteric borders. Before you staple, we can take a look at it too. Okay, so this side looks good. All right, I'll take a look at the backside. And then put your finger in here since you can't do it through... All right. Okay. So now I've got two limbs - when you fire this, it's going to take out that section between the two limbs so that these are now connected. We cut off this part here, normally we'd go around there, can't do that anymore. We're going to make our functional end-to-end connection here and then close that defect. That fires the staples. Hold that. Mm hmm. And then when you come out, don't open too wide, you can come out slowly. And then pull out because the inside of this staple is going to be dirty. Great. Yeah. Is there bleeding inside? So we look inside the lumen. You can see a little bit of succus in there - no bleeding. Just succus. Mm hmm. So now we have the two limbs, proximal and distal limb, we have a connection between the two. Now we just have to close this defect. You want one more babcock? Yeah, maybe two more. May we have another babcock? Your staple line's off-set. Yes, one side's here, one's - well one's here, one's here. Okay. Now let's - yeah, take a little bit less. GIA 60? What size do you have? I have a 60 and a green and blue. 60 is fine, yes. So take a little bit less with both your babcocks there. Is that okay? Yeah, that's fine. Let me position this one here. All right, who's going to do this one? So proximal, distal, we've made our connection between the two inside, now we have this one defect to close, and then you're good. I'll do it. You got it? All right, here you go. The first one you - when you come around, you want to try to hug the babcocks, that's why we put them there, so we don't decrease the lumen when you anastomose it. So don't even touch this yet. So you kind of lock it in place. Yep. And then you can squeeze once just to tighten it. Slowly, and as you're doing it position it, yep. And then we can relax a little bit on the anastomosis. You don't to be too far off the end there because that'll be open soon, yep. Hugging the babcocks. I think that looks pretty good. Do you agree here? Yep. Okay, so then your next squeeze will fire the stapler. So you can relax. So, relax. Now you make sure everything you're - you're good because once you do this, you've fired the staples. Okay. Mm hmm, and then try to not have so much tension so that you're like yanking at the end, there you go. So squeeze now. When you relax, it'll stay there. Mm hmm. Now normally with your other GIAs, you move the pine and it - It cuts the tissue. You don't have that option here. You have to do that manually, so you get your 15 blade. What do you have there? 11. 11 will work. There's a groove right there, okay? Do you see it? It's right here. So if you kind of slide your 11 blade... So you start with it in a groove, and you try to stay in that groove. Now see how you're holding that, like a pencil, that's not going to work, you want to hold it... So you have one hand on this, other hand there, get in that groove, and cut this off, and control the knife so you don't cut your partner. Okay? This is for doing fine stuff. Plastic Surgery. In the groove. Left hand controlling the stapler. Yep, keep going. Good. Go back over it again. In the groove. Mm hmm. Okay, now let's cut right there. Why don't you just come up over here. Almost. All right, knife back. Knife back. Thank you. Trash. All right, relax, and we'll see some pumpers from the... Nothing, hemostatic - relatively. Do like a U-stitch? Figure of eight. Can we dunk the ends? Sure. All right, let's get that bleeding controlled. So now that you've already done one three, you can actually just hold this up. Needle back. Now see how you left yourself short there? No need to do that. Do you have 3-0 silk? Suture scissors. I do. So try - I know this is mesentery here, but - but try and get a bite here, and here, and then I'll dunk this through. Yeah, I think so - just so - yeah. You want to dunk that too? Mm hmm. So go ahead and pull - pull some more through, there you go. Needle back. Thank you. This is just a weird - That's fine, we can do it - we'll do another one a little bit wider. Another stitch, please. Let's do one here and here, and then we'll... Remember, this is not strength here, so... There's no - there's not really serosa here. Should I just leave it then, or just... Yeah, I do not dunk. Okay. But I want to give you some autonomy. Okay, I mean, I can leave it, if it doesn't make a difference, but the staple line... So once - we'll close that defect and... Okay. No, we're just Lemberting. Dunking is like for the corners, the Lembert is... Needle back. So the Lembert is technically not necessary either, but there's still some people that do it. So these are not benign moves here, right? You can bag a vessel there, in the mesentery, doing this maneuver. Mm hmm. Let's close the mesentery defect with a couple. Do you - I usually use Vicryl. Yeah, Vicryl, you can - one or two Vircryls in there. Okay, may I have a 3-0 Vicryl, please? So this is not a strength layer, this is just closing that defect - it'll scar down, this prevents internal hernias. Do you want to run this? Um - sure. This is such a small defect, it may be irrelevant. Sorry.

CHAPTER 5

We're - we're going to do something about that. But first what we want to do is take up the colon, look for the ureter - penetrating injury, you have to identify the ureter - Okay. So, we'll mobilize that, identify the ureter, then we'll get a better look at that, and decide what to do about that. Okay, well while we're waiting here, let's go ahead and get this lesser sac opened and look inside the posterior wall of the stomach. This is already magically opened for us. Can we have two malleables, please? The two biggest ones you have. So the one that curves up - you're going to get all the way up to the GE junction, right? Because way up there is where injuries hide. And, you know, pull this back, and as you're pulling this back, you allow the posterior wall of the stomachs to fall in to view. You're looking for holes there. But the first thing you do when you look in, you look for blood, bile, or bits of food. Then we're going to do this, okay? So, get hooked back up again, Dr. Suah. So, the lesser sack is open. Posterior to the stomach. The first thing we look for is do we see any bile, blood, or bits of food that would indicate a potential hole in the stomach. Now again, you take this malleable curved towards the ceiling, all the way up to the GE junction. Another one curved towards the floor. And this you have to fan out the stomach from like left to right or right to left, whatever you want to do, but this takes several maneuvers to see the entire posterior wall. We're going to fall in slowly, and as the posterior wall falls into view, you're looking for gastric injuries, okay? So, you get in the best position where you can to see that. If you need to move your body, move your body. Good. Yep. You repeat that maneuver a couple of times, left to right, and then Dr. Suah can practice. And then Dr. - what's your last name Doctor? Kayhill. Kayhill. We'll let you try one sweep, so you can see what it feels like. It's way up at the GE junction - that's where you'll miss an injury, up at the GE junction, so make sure you're happy that you've seen that. All right, malleables out. So, lesser sac.

CHAPTER 6

All right, let's get this right colon mobilized. So this thing, we're going to decide if we can just oversew it, or does he need an ileocecectomy, okay? Okay. So we want to avoid the ileocecectomy. Do you want the Bovie extender for mobilizing the right colon? But let's just get this... All right, so over in here, the ureter comes down. From the kidney. So it's quite possible that it was injured by this bullet. And the urethra doesn't just sit there easily identifiable, so we're going to have to mobilize our colon. We're going to open it? So we can pull this up and identify the ureter and convince ourselves along its entire length that it has not been injured by this bullet. So is that the white line, or are you just going where the defect is? I think this is white line, here. Here. There's the white line. Yeah, and it comes here. Okay. All right. So the white line of Toldt is an avascular peritoneal reflection. That's what we will divide to mobilize the colon, so here - see, it's right there. Mm hmm. Yeah, I know y'all are sick of hearing me talk. But there's an audience out there that is interested in the work you're doing. They're like, "Dr. Williams, I've had enough! We're good!" Ooh, gallbladder - long DeBakey, please. Gallbladder, liver. Okay. All right. There you go. Yes, yes. Now right through there, Dr. Suah. Around here. That's okay, you can always go what you know. Get this... Yeah. Is this coming up at all yet? Yeah, I think it - and then there's some easy give here. All right, get your right angle in there. Mm hmm. Good. There's our appendix here, behind your finger. So that should be coming up some now, so something is... It's still a little stuck up here. What's tethering us down? So was that it right there? I mean, kidney's right here, so it might be right here. Is this it? Right here, yeah. May I have a DeBakey? Yeah. There it is. Here. In there right there. Buzz. Buzz. Buzz. Let's see what you got here, with two hands. I think it's here. Suction. Don't go past my tip of my finger. All right. Psoas muscle is there. Mm hmm. So, look at your ureter, there it is. Beautiful. So there is the ureter. It's intact up to the kidney. So we had a penetrating injury to the right side of the abdomen. We've identified our ureter. It is intact. So nothing to do there. I think I feel it. I think. In the colon? You feel the intracolon bullet? Here. Right here, yeah. See? What? It's right here. Wait - Right at this spot. Right here. It's in between - it's right here. Oh. If you pinch right here. I think it is in the colon. Okay, all right. I hate to give this guy an ileocecectomy. Do you feel it? I felt it for a second there. Okay. Yeah, I feel it, I've got it. Let's see if I can milk it to that hole. DeBakey, please. Well - let's see if we can get this - open this hole. Mm hmm. Are we trying to milk it back out? I was going to if I could, but it's not easy, but I just want to open this up to see we can just repair it primarily. Do you want me to make an enterotomy with the Bovie? Yeah. Let's see if we can pick up the ends with two DeBakey's first before you make the enterotomy. Okay. Yeah, let's get this all the way up, mobilized around the hepatic flexure so we can pull it way up. Okay. A right angle, please? Thank you. We're just going to take this all out, so this... Yeah, I don't feel good about leaving this here, it's just... Okay. I don't know. Yeah, I mean I... Staple across it? Well the bullet's inside, so... I'm not worried about the bullet, the bullet will pass. He can poop it out. But I guess I'm like is there another - is there an injury that we can't see? Yeah, that's what - we'll get this pulled up so we can see the backside to be sure. And while we're doing that, I'll decide about taking it all out or leaving it in. Okay. So the debate here is he has this hole that you see right there at the cecum. The bullet is intraluminal - inside the cecum. We can actually palpate it. So the question is - does he need an ileocecectomy, or can we just repair this wound primarily? But before we make that decision, we're going to mobilize around the hepatic flexure so we can get a good look at the entire right colon. I'm not worried about the intraluminal bullet, that'll pass. See, that's where it's tethered down in there. Airplane, patient left. So we can save our surgeon's back. So you see that - so right angle - so this right here, that's what's holding - keeping you tethered, so right angle there. And our ureter is down, so that's safe, we're not pulling it up in our specimen, we don't want to do that. So we'll continue to check that over and over again, not get complacent about that. All right, let's take two hands here because something is... Right, so get through that. That's - that's got to be tethered. Always check to make sure there's no tubular structures of importance. Okay, then do another check. Okay. Duodenum's right there, I think. So we have duodenum. Yep. Okay, do a Kocher. Just get around the corner. LigaSure. You want me to LigaSure that? Um, no. Bovie. There's something up down there. So let's come around this, but not through the appendix. That's good. So once you get the hepatic flexure down, I'll be satisfied with what we can do. All right, I think we're good there. It looks pretty mobilized. Yeah, I think that's good there. Let's see if we can feel that bullet again. I think we're going to just... Let's see if we can get the two babcocks possibly in that hole. If not, we can just extend this hole, milk out the bullet, staple this off, and watch it.

CHAPTER 7

I won't go too crazy, I could cause more damage than... Mm hmm. Well... I think I'm just going to let that pass if we can. Let's just staple this off. Okay. Just use GIA? Yep. Can I have a babcock? Thank you. So we're debating what's the least morbid procedure we do. Ileocecectomy, he loses terminal ileum, appendix, ileocecal valve, and his right colon, which means he's going to have watery stools for the remainder of his life - this will - well not for the rest of his life, for a while. This will adapt at some point, but it's also a morbid of a procedure. Do we go take out the bullet - if it was right there and easy to get, I'll pop it out, but we don't want to do more damage than - going after it than just by leaving it, so that will pass with his stool. So we're just going to staple off this defect here. Yep. Is that a good specimen or no? Yes. Separately? Separate specimen: partial cecectomy. Partial cecectomy. All right.

CHAPTER 8

We opened him up. We found the two holes in the terminal - or distal jejunum. Found this hole, cecum. Found a retroperitoneal hole, right side. We've explored the entire bowel. We looked at liver, diaphragms, our retroperitoneal hematomas, the lesser sac. Anything we did not look at? Nope, we identified the right ureter. Identified the right ureter. Okay, so now it's my turn to go through everything. All right, so you can never do your exploration too many times for penetrating trauma. So I'll do it with our chief resident. So we'll start with our RP hematomas, okay? So, transverse colon up, look down. Still nothing there. Mm hmm. Stomach down, liver up. Nothing up in there. Mm hmm. Now if you need to get vascular control quickly for him hemorrhagic shock, you can feel right up there, and you can feel the aorta there. You just put your hand down there, that'll stop the bleeding to the abdomen for awhile. Switch spots with your medical student, make them stay there, then get all your - then get all your equipment set up and ready to go, okay? All right, so RP hematoma - that's zone one. Big Rich, please. Zone one is clear - inframesocolic and supramesocolic - zone two is our perinephric hematomas. So on the left zone two, pull that up, that is still looking good. Go to right. Normally, I just do it in a circle, but for teaching purposes, we'll just go to the right perinephric, right zone two. There's our psoas hematoma. So you must have - that must be just a fragment of this in his cecum because there must be a bullet back there somewhere, right? Or actually, it can't be this way, so maybe it is - that could be the whole bullet, came through there, hit the cecum. All right, zone two looks okay. Mm hmm. Now down to zone three. Do you have a smaller Rich? All right, pelvis. Looks good. All right, iliacs - both sides look okay, good. All right, relax. So now we're going to run the bowel together. So, colon up. So fanning it out. Milking, make sure we're not missing any other holes. You and I are working together. Partial cecectomy. Yes, sir. Just routine, doc? Yep. Okay. Thank you. The staple line looks good. So you don't Lembert any staple lines? No. Okay. There's something oozy over here. All right, now colon - now again, the base of the mesocolon is where penetrating injuries can hide. Okay, big Rich, please. I need to take a look at the splenic flexure. Also take a feel of the spleen. The spleen feels good. The splenic flexure looks good right here. All right, left colon, descending colon, that looks all good. All right, so we've run the bowel several times. Our anastomosis looks good. Our repair looks good. Feel up on the liver. The diaphragm - we left the Falciform up - same on the left side. Take a look at our lesser sac again. Can I have the malleables back, please? So there's the pancreas. Yep. I forgot to point that out to our team when we were there before. Pancreas is here. All right. Anything else doctor? I think that's it. I think some - I don't know if this is just run down. Let's watch this for a second. All right, so our bowel's back in anatomic position. We put... Looped-O max - loop number one max on. Loop number one? Times two. Number one? Times two. He's got a really shortened omentum, doesn't he? Omentum, yeah, it seems like it's all kind of rolled up a little bit. Okay. We're going to check her OG position, please. Actually, she shouldn't need one, right? Pardon? We can leave one in. Do you want to leave an NG tube, or take it out? We can leave it in since he did a small bowel anastomosis. An NG, or what? NG, please. Oh, it's in - well, that's okay. Yeah. Okay. All right, so let's summarize while we're getting things done here. Gunshot wound to the abdomen with peritonitis - exploratory laparotomy, midline incision, thorough exploration. We found two enterotomies, distal jejunum. And we found cecal - cecotomy - a hole in the cecum. We also saw a hole in the retroperitoneum. And here's our external hole. So the bullet came in here, went through here, and then - the cecum, and through the small bowel. We ran the entire small bowel, ran the large bowel. We checked for RP - retroperitoneal hematomas, zone one. Zone two - Zone one around the - which is aortic / IVC, inframesocolic, supramesocolic, zone two, perinephric, zone three down in the pelvis, which would be iliac injuries - nothing there. We looked into our lesser sac, checking out the posterior stomach, no injuries there. Felt the liver, diaphragm, spleen. And that concludes our exploration. We've done that several times. We are happy that we have not missed any other injuries. Yeah. Our repairs included that anastomosis, which was a stapled, side-to-side, functional end-to-end anastomosis. And our partial cecectomy was stapled. Now we're going to close. I don't feel an NG tube. Yeah, I'm trying to pass it in the nostril, yeah, sorry - I'm getting a little bit of resistance I feel like. So for our postoperative care, Mm hmm. He was not critical during this case, so we're going to extubate him in the OR, so he will be extubated, go to the PACU, then go to the floor post-op. He will have an NG tube, but that's, you know, we can debate whether he actually needs one or not. I tend to not leave them in. But I'll - Dr. Suah will be taking care of this patient, so we can leave one in. I'm pretty aggressive about giving them PO, post-op day one. But we thank you all for tuning in, we're just actually going to just close the abdomen with - close the fascial layer, then some skin staples, and we'll be done. Oh, we got to feel the - first - we're getting the NG tube in. Yeah, you know, Dr. Williams I'm getting a lot of resistance up here in his nostril. Okay. Yeah. We can leave it out. We'll leave it out then. Yeah, I just don't want to poke too hard and cause some trauma back over there. Okay. Yeah. We'll take the stitch, please. All right David, this is you right here. And do you want to do the bottom? Yeah, I usually start with the bottom first because you want to get the guts closed in. Because sometimes, if you come from the top, then you can't close the bottom because everything's pooching out here. So I just always do on the bottom first. Do you want me - I was saying do you want me to do it? Oh yeah, kid, yeah, so switch sides with me. Okay.

CHAPTER 9

And X-ray is free to come anytime, please. So since it was - this was an emergency case, we didn't count beforehand, so we always routinely do an X-ray beforehand for either - to make sure that there's no retained foreign bodies. We didn't leave a laparotomy pad in there somewhere or an instrument. The count is correct, Mike. Thank you very much. 1 cm back, 1 cm travel for these throws. The fascia is a strength layer. I hope everybody that's watching has learned something and enjoyed Friday evening on trauma call at the University of Chicago Medical Center. We're just getting started. Just getting started. The team was sitting out for dinner when this case came in. This was perfect because this is a classic - clinical case that we deal with frequently in our actual practices. It is a case that comes up a lot on surgery exams and oral boards. and it really encompasses all the principles of trauma surgery. So first is knowing the mechanism. We knew he had came with a gunshot wound to the abdomen. Next is is he stable or unstable, which means is he in shock, low blood pressure, which could indicate vascular injuries or not. He came in stable. That does not mean he doesn't have an injury that needs an operation. We watched him for a little bit in the ED because at first he didn't act like he had an intra-abdominal injury. But all indications were that he should have had one. So before rushing him out to the OR, since he was stable, we gave him a few minutes to declare himself, and... Hey is that - are you going through the umbo there? No. No, I think it's right here. Okay. I'm trying to get the other half of it, like because I don't want to go through it, so I just... But he developed peritonitis. Which right there, you're done. So penetrating abdominal trauma with peritonitis mandates an exploratory laparotomy. Stitch please - we'll switch sides. Can you grab that life there, David? So again, X-rays -this is an emergent case, we didn't count all of our instruments, we're doing a X-ray in the OR before we're completely closed to make sure we haven't left anything inside the belly. It's a safety precaution. It's all right, oh, we keep flying this thing. We can airplane him back to the right, please. All this time you've been like reaching over there. I'll have the next size down malleable, please. 1 cm back, 1 cm traveled in the fascia. So some more pearls: closure of the fascia is important, we don't want any hernias to develop, or immediate post-op, you have evisceration, which means that you'll be on the floor. The wound comes open, and then our bowel is coming out. I also want to avoid wound infections, want to stay sterile. Make sure we have hemostasis at the end. Put a dry sterile dressing on. So even though we're at the end of the procedure, it's not any less important than anything else we've done so far. And also notice as we're doing this, I have this malleable here. That is to prevent accidentally sticking the bowel with this needle as it goes into the abdomen. Are we ready? X-ray? Yeah. All right, we're going to put this out of the way here. Our needles are protected. Cover up the wound, please. Then we're going to step out of the way for a moment while they take X-rays and make sure there's nothing left in the belly. Tell her she needs to take two: a low chest and a high pelvis so she gets the entire abdomen. Okay. Can I look? I just need to get the bottom done. Okay, one more. Thank you. So we still got the big bullet still sitting in there. Oh, yeah. So that's just a fragment that's in his - do you see it? Yeah, so the main bullet's still there. Okay. It's probably posterior back in like the psoas muscle where we saw that hole. Yeah. So that's where that corresponds with. All right, let's get this thing closed up. Malleable, please. So our x-rays show we have nothing left in the belly. Can I have the narrowest malleable you have, please? Thank you. You still got a couple more to go? Maybe one more. Mm hmm. One more, use the back of your.... The count is correct doctor. Thank you very much. Put your thing back, yeah. Okay. I just can't pick it up. Suture scissors. David's got them, good. Got them. So for these sticks we do like that you need to kind of go down towards the - yeah. Towards the back room? Normally we tell you at the tips for the other sutures, but these are - these are thick, tough sutures meant to hold the fascia together so you need to get down to the - the meat of the scissors. So you're not chewing at it. And these you cut at the knot also? No, no, this you - leave a tail on these. Leave more of a tail on it, got it. Since it's slight, monofilament. It's a monofilament, so theoretically they can unravel. Uh huh. All right, wash this out, hemostasis, staples, dressing.

Is now a good time for a debrief? Yes. Go ahead, doctor. All right, the procedure performed: exploratory laparotomy, enterectomy times one with stapled anastomosis, partial staple cecectomy. Wound classification three, incision, deep superficial layer, specimens labeled correctly - two specimens. Yep, partial cecectomy and small bowel. EBL? 100? 150, Let's do 150. Post-op VTE plan? Squeezers, put him on his normal trauma prophylaxis. Foley stays? Foley? Eh? Do we need one? We can take out the Foley. Foley can come out. All right, cool. Wound care - has a dressing. Recovery concerns? Nope. Extubate to the PACU. Do you have a discharge date, doc? Discharge date - let's give him five days. 5 days. ID band present? Yep, I just put it on. Equipment - no issues. Surgeon - Brian Williams.