Management of the Major Coagulopathy with Onset during Laparotomy

Abstract

An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: Does it increase abdominal wall closure rates?

“…1,[4][5][6][7]9 Although the technique of perihepatic packing was founded in 1908 with Pringle's discussion of hepatic trauma, 43 the modern interpretation of this work occurred in the late 1970s, [44][45][46] followed by the concept of truncated operations with concurrent intra-abdominal packing for patients in physiologic extremis by Stone and colleagues in 1983. 47 This philosophy was then coined "damage control" by Rotondo and colleagues, given its obvious conceptual similarity to the Navy's use of the same term. 48,49 Although this concept has resulted in a substantial improvement in mortality when applied to the correct patient population, 49 it also commits the patient to a series of subsequent operative procedures aimed at restoring gastrointestinal continuity and abdominal wall closure.…”

Damage Control - A Paradigm Change in Trauma and Emergency Surgery

“…The true reawakening occurred in 1983 when Stone and his co-workers published a series of 17 severely injured patients treated with abbreviated laparotomy and planned reoperation with a survival rate of 76% when compared with 14 similar patients undergoing definitive repair with only one survivor (7%) (6). The concept was further refined by Ivatury in 1986 (7) and Burch in 1992 (8).…”

Systematic Review of Evidence-Based in Beneficial Preventing Hypothermia for Adult Trauma Patients in Accident.

“…Jurkovich et al (7) found that no trauma patient whose core temperature fell below 32 °C survived, and they regarded this as the critical temperature for survival. Hypothermia is recognized as one pillar of a -lethal triad‖ (hypothermia, acidosis and coagulopathy) of homeostatic failure that is believed to mark the limits of ongoing intervention, and necessitates an -abbreviated‖ laparotomy (26)(27)(28)(29)(30) .…”