Exploratory Laparotomy
What the Examiner Expects
Emergency surgical exploration of the abdomen through a midline laparotomy incision, the foundational trauma operation. The examiner expects you to describe the systematic approach: midline incision, evisceration of bowel, four-quadrant packing to control hemorrhage, then methodical exploration of all abdominal organs. Inspect the entire GI tract from esophageal hiatus to rectum, liver, spleen, kidneys, diaphragm, mesentery, retroperitoneum (zones I, II, III), and major vessels. Priorities: control life-threatening hemorrhage first, then control contamination (staple off perforated bowel), then definitive repair when the patient is stable.
Key Examiner Focus Points
- Midline incision from xiphoid to pubis for maximum exposure
- Systematic exploration: four-quadrant packing, then eviscerate and inspect all viscera
- Indications: penetrating abdominal trauma with peritonitis, hemodynamic instability, GSW traversing peritoneal cavity, blunt trauma with free fluid and instability
- Control hemorrhage first, then contamination
- If unstable: damage control — pack, stop bleeding, close temporarily
Common Curveballs
After packing all four quadrants, the only source of ongoing hemorrhage is a central retroperitoneal hematoma (zone I)
Zone I retroperitoneal hematomas must ALWAYS be explored regardless of mechanism (blunt or penetrating). This zone contains the aorta, IVC, and their major branches. Obtain proximal and distal control before opening the hematoma. Left medial visceral rotation (Mattox maneuver) exposes the suprarenal aorta; right medial visceral rotation (Cattell-Braasch) exposes the IVC.
Patient is in extremis — pH 7.1, temperature 34°C, coagulopathic after 10 units PRBCs
Lethal triad: hypothermia, acidosis, coagulopathy. This patient needs damage control surgery — pack for hemorrhage control, staple off bowel injuries without anastomosis, temporarily close the abdomen (vacuum-assisted closure), and transfer to ICU for resuscitation. Return for definitive repair in 24–48 hours once the triad is corrected.
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