II. Associated Conditions

  1. Liver Laceration
  2. Splenic Rupture
  3. Renal Injury
  4. Pancreatic Injury
  5. Hollow viscus (bowel perforation) or Lumbar Spine Injury
    1. Seat Belt
    2. Deceleration injury
  6. Rectum or other bowel injury
  7. Gastrointestinal Bleeding

III. Indications: Diagnostic Testing

  1. See precautions below
    1. Do not delay an exploratory laparoscopy that is clearly indicated
  2. Suspected occult internal bleeding with decreasing Hematocrit and no obvious source
  3. Non-diagnostic examination with higher clinical suspicion
    1. Equivocal peritoneal signs with abdominal tenderness and guarding
    2. Altered Level of Consciousness and suspected Abdominal Trauma
    3. Negative abdominal exam but high level of suspicion based on Mechanism of injury
  4. Bony Fracture with associated abdominal tenderness or guarding
    1. Multiple lower Rib Fractures
    2. Lumbar transverse process Fracture
    3. Pelvic Fracture

IV. Examination

  1. Complete abdominal exam
  2. Rectal examination
    1. Decreased rectal tone (spinal injury)
    2. High riding Prostate (Urethral transection)
    3. Bloody stool on rectal exam

V. Imaging

  1. First-line studies
    1. FAST Exam
    2. CT Abdomen and Pelvis
      1. Perform with IV contrast
      2. Consider oral and rectal contrast if time allows and not contraindicated
  2. Abdominal XRay
    1. Evaluate with CT Abdomen and Pelvis (or UGI with gastrograffin) if red flags are positive
    2. General suspicious KUB findings
      1. Peritoneal free air mandates emergent laparoscopy
      2. Ileus
      3. Visceral displacement
      4. Lumbar compression Fracture
    3. Duodenum or pacreas injury signs
      1. Psoas shadow absent
      2. Retroperitoneal gas
      3. Linear air shadows at duodenum or overlying the right Kidney
    4. Splenic Injury signs
      1. Splenic shadow absent
      2. Gastric air bubble displaced medially
      3. Left psoas and left renal shadows obscured
      4. Left upper quadrant soft tissue density

VI. Diagnostics

  1. Diagnostic Peritoneal Lavage (not recommended)
    1. Rarely performed now in United States where Ultrasound and CT Scans are readily available
    2. Typically FAST Exam followed by CT Abdomen and Pelvis is performed in Trauma

VII. Precautions

  1. Do not delay emergent exploratory laparotomy when indicated
  2. Peritoneal cavity extends well into chest
    1. Anterior superior diaphragm boundary: Nipple Line
    2. Posterior superior diaphragm boundary: 4th intercostal space
  3. Although distracting injury may theoretically hide abdominal findings on exam, it still has 90% Test Sensitivity
    1. Rostas (2015) J Trauma Acute Care Surg 78(6):1095-100 +PMID:26151507 [PubMed]

VIII. Management: Exploratory Laparotomy Indications

  1. Unexplained shock
  2. Visceral Trauma (e.g. evisceration)
  3. Gastrointestinal Bleeding
    1. Blood in Stomach
    2. Blood aspirated via Nasogastric Tube
    3. Rectal bleeding
  4. Peritoneal signs on examination
    1. Abdominal distention
    2. Absent bowel sounds
    3. Peritonitis
  5. Suspicious findings on adominal XRay or CT Abdomen (e.g. Abdominal free air)
  6. Retained Foreign Body into the peritoneal cavity
    1. All abdominal gun shot wounds should be surgically explored
    2. Stabbing weapon

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