Trauma Laparotomy and Splenectomy: Management and Complications

Trauma laparotomy + Splenectomy
Trauma laparotomy is a surgical approach warranting an emergency invasion of the
abdominal cavity following the reporting of blunt and penetrating abdominal trauma (Salotto
& Jurkovich, 2017, p. 523). The preliminary objectives of trauma laparotomy approach are
based on the repair of deteriorated abdominal regions or organs, management of
gastrointestinal contamination, and haemorrhage control. The surgeon requires adopting a
time-sensitive and comprehensive approach for resolving the abdominal injuries through the
execution of single or multiple surgical phases. The trauma laparotomy approach focuses on
resolving the immediate threats to the patient’s life. For example, the effective control of
heavy bleeding or exsanguination followed by resuscitation interventions facilitate the
patient’s recovery process inside the operation theatre. The resuscitation interventions include
physiologic insult’s counterbalancing, coagulopathy treatment, intravascular volume
maintenance, and fluid/blood product administration. Splenic injuries substantiate the
requirement of laparotomy intervention in the context of removing the injured splenic
portion. Splenectomy requirement in most cases is based on the management of splenic
bleeding following the occurrence of penetrating trauma
(The_American_Association_for_the_Surgery_of_Trauma, 2012). The presented essay
effectively discusses pre-operative, intraoperative, and postoperative phases of laparotomy
and splenectomy in the context of blunt splenic injury. The essay also discusses the patient’s
physiology, anatomy and their implications on the pre/intra/post-operative management. The
essay addresses trauma-based adult versus paediatric splenectomy, anaesthetic management,
clinical complications, and situational awareness of trauma laparotomy.
The trauma laparotomy intervention requires surgical invasion through the anterior
abdominal wall into the abdominal cavity (Rajaretnam & Burns, 2019). The abdominal wall
encapsulates the abdominal viscera and abdominal cavity that warrant systematic invasion
followed by the reported occurrence of blunt abdominal trauma. The trauma laparotomy
intervention warrants a systematic invasion of the anterior abdominal wall components
including peritoneum, transversalis fascia, pyramidalis muscle, transverse abdominis muscle,
rectus abdominis muscle, internal oblique muscle, and external oblique muscle. Other
significant components include Scarpa fascia, Camper fascia, subcutaneous fat, and skin
(MacKay & Varacallo, 2019). The rectus abdominis muscle bifurcates through linea alba
across pubic symphysis and xiphoid process. The rectus abdominis collaborates with 7, 6, and

5 costal cartilages, xiphoid process, and pubic crest. The stabilisation of the pelvis and
abdominal visceral compression occurs under the influence of rectus abdominis muscle. The
innervation of T7-T11 nerve roots of the thoracoabdominal nerve across the rectus abdominis
muscle maintains its connectivity with the nervous system (Sevensma & Pihl, 2019). The
pyramidalis and rectus abdominis muscles are enclosed by anterior and posterior rectus
sheaths composed of transversus abdominis, internal oblique, and external oblique muscles.
The surgeon, during trauma laparotomy, requires invading these anatomic structures without
radically disrupting their nerve supplies and vasculature. The indications of trauma
laparotomy include trauma induced obscure gastrointestinal haemorrhage, abdominal
adhesions, specimen extraction requirement, intestinal obstruction, peritonitis, perforated
viscus, haemoperitoneum, and blunt abdominal trauma (Prince, et al., 2017).
The surgeon requires a thorough understanding of splenic anatomy and physiology before
undertaking splenectomy for treating blunt splenic trauma (Kapila & Tuma, 2019). The
spleen consists of white pulp that initiates adaptive immune response through the induction of
white blood cells across the central arteriole. The white pulp of spleen is based on T-cells/
periarteriolar lymphoid sheath (around marginal zone) and B-cells (around innermost and
germinal regions). The red pulp of the patient’s spleen is encapsulated by white pulp
containing venous sinuses and splenic cords. The organ structure of spleen is based on
splenic cords containing fibrils, reticulin, and monocytes (Chaudhary & Panuganti, 2019).
These structures effectively facilitate the wound healing process. The macrophages inside the
splenic cords are encapsulated by vascular sinuses and assist the elimination of aging
erythrocytes, abnormal cells, and antigens. The spleen is covered by a trabeculae-based thin
fibrous capsule. These fibrous bands or trabeculae facilitate vascular transportation across the
splenic structures. The blunt splenic injury substantiates the requirement of initiating ALTS
(advanced trauma life support) protocol followed by rapid evaluation of critical trauma and
resuscitation requirement. The fluid resuscitation is paramount to blunt splenic trauma
followed by a thorough physical exam of the injured patient. The CT assessment of
haemodynamic stability, active bleeding, and intraparenchymal injuries is highly needed
before initiating the exploratory laparotomy intervention (Kim, et al., 2017). Splenic trauma
is based on blunt splenic tissue injury, vascular disruption, haematoma, and lacerations. The
trauma grades 1-3 warrant immediate hospital management followed by surgical intervention.
The initiation of serial imaging is highly required for evaluating trauma-based peritonitis and
haemoglobin reduction in the context of planning total/partial splenectomy and/or

angioembolisation. The evacuation of splenic haematoma following blunt trauma is highly
needed to minimise the occurrence of vascular complications.
The patients with blunt abdominal injuries require different trauma care levels based on their
clinical complications (Coccolini, et al., 2017). The level-1 trauma care is based on the
management of severely traumatised patients (Soto, et al., 2018). The level-2 trauma care
reciprocates with the treatment of seriously injured patients in the absence of specialised
resources or clinicians. The level-3 trauma care is undertaken by on-call staff inside the
community hospital. The level-4 trauma care warrants patient stabilisation through the
utilisation of advanced trauma life support system in the absence of an immediate hospital
intervention. The blunt abdominal trauma occurs under the impact of compression, shearing,
deceleration, acceleration, and other similar forces. Some of the examples of blunt abdominal
trauma include motor vehicle accidents, contact sports, aggravated assault, falls, and low
energy trauma (O'Rourke & Burns, 2019). The deceleration and acceleration injuries are
based on blunt trauma that usually leads to the rupture of the thoracic aorta and greater
vessels. The motor vehicle accidents include vehicle collision that eventually leads to the
penetration of the vehicle’s rigid surface into the body structures of the driver or occupant.
The splenic trauma in adult patients leads to the development of minor, moderate, and severe
lesions that eventually require their medical management or splenectomy. The adults or
children affected with severe or World Society of Emergency Surgery (WSES) level-4 spleen
lesions require splenic salvage following laparotomy and splenectomy (Waseem & Bjerke,
2019). However, paediatric patients require vaccination intervention following their total
splenic exclusion in the context of reducing the risk of infections. The paediatric patients
require undergoing splenectomy following their impalement, bowel evisceration, peritonitis,
coexisting injuries, absence of conservative management, and haemodynamic instability. The
surgeon, however, requires preserving the paediatric patient’s spleen to the maximum
possible extent during the surgical intervention. The splenic trauma follow-up in paediatric
patients is based on the assessment of pseudoaneurysm (requiring angioembolization) and
haemodynamic stability (Zhu, et al., 2015). The postoperative care of the
hyposplenic/asplenic paediatric and adult patients is based on their active immunisation
against Neisseria meningitides, Haemophilus influenzae, and Streptococcus pneumoniae.
However, the clinician should administer the vaccination intervention within 14 days of
splenectomy (Stockinger, et al., 2018). The splenectomy candidates also require yearly
vaccination against influenza. The malaria prophylaxis is also required for adult or paediatric

patients who intend to travel after undergoing partial or total splenectomy. The postoperative
phase of splenectomy requires the administration of antibiotic therapy following the reported
occurrence of constitutional symptoms based on chills, malaise, and unexplained fever. The
primary care practitioners require re-evaluating the patient’s angioembolisation or
splenectomy status while administering health care interventions during the post-operative
period (Rosenberg, et al., 2018). The splenectomy patients experience a high risk of
infections during the initial two years of their surgical interventions. Accordingly, their
postoperative immunologic management is highly warranted while improving the clinical
decisions based on reported physiological effects and injury outcomes.
The preoperative trauma laparotomy and splenectomy management are based on the thorough
documentation of the patient’s clinical complications, injury type/level, comorbidities, and
bleeding status (Zambouri, 2007). The clinicians require evaluating the patient’s overall
health status and hidden conditions that the patient might experience during the intraoperative
and postoperative phases. The clinicians require undertaking the patients’ perioperative risk
assessment and stabilising the vital signs/medical condition in the context of reducing their
risk of perioperative mortality/morbidity. The clinicians and nurses require configuring an
effective perioperative health care plan while concomitantly enhancing the patient’s or
caretaker’s awareness of recovery process, perioperative anxiety, postoperative pain,
intraoperative complications, anaesthesia, and trauma laparotomy. The perioperative
assessment reciprocates with the evaluation of the patient’s complete blood count, activated
partial thromboplastin time, international normalised ratio, creatinine/electrolytes, fasting
blood glucose, electrocardiography, and chest radiograph (Akhunzada, et al., 2018). The
perioperative risk assessment also concords with the evaluation of the patient’s physical
status based on the ASA (American Society of Anaesthesiologists) classification system. The
clinicians require evaluating or ruling out the patients’ moderate or severe systemic
disturbance and psychiatric/biochemical/physiologic complications before the initiation of
trauma laparotomy protocol.
The intraoperative phase of trauma laparotomy requires managing the patient’s
haemodynamic stability and haemorrhage. The intraoperative phase reciprocates with the
patient’s transfusion management, vasopressor administration, and contamination elimination
(Harvin, et al., 2017). The surgeon requires maintaining the patient’s mean arterial pressure
during the intraoperative phase of trauma laparotomy/splenectomy in the context of reducing