Oral Board Case: Trauma Laparotomy

How do you initially approach this patient on arrival?

Expected answer

Run the ATLS primary survey—Airway, Breathing, Circulation, Disability, Exposure. Place two large-bore IVs, send a trauma panel and type and cross, initiate balanced resuscitation with blood products, and activate massive transfusion as needed. Obtain key history: type/energy of penetration (low energy in this knife wound), location/number of wounds, time since injury, and hemodynamic status. Do not delay for unnecessary imaging in an unstable patient.

This patient is hypotensive, tachycardic, with peritonitis. What is your decision and why?

Expected answer

He has two independent hard indications for operation: hemodynamic instability and peritoneal signs from penetrating abdominal trauma. He goes immediately to the OR for emergent exploratory laparotomy. No FAST, CT, or local wound exploration is needed—they would only delay definitive control of hemorrhage and contamination.

If instead the patient were hemodynamically stable with a soft abdomen, how would your workup differ?

Expected answer

For a stable patient without evisceration or peritoneal signs: assess for fascial penetration. Mark wounds with radio-opaque markers, get an upright CXR to look for free air/pneumoperitoneum and concomitant thoracic injury, and perform a FAST. Free air or free fluid mandates the OR. With a knife (low-energy) wound and no clear signs, perform local wound exploration; if the anterior fascia is violated, proceed to diagnostic laparoscopy/laparotomy or DPL based on findings. If no fascial penetration, irrigate and close the wound and observe/discharge.

What are your priorities and sequence once you open the abdomen in this unstable patient?

Expected answer

Make a generous midline incision. First control hemorrhage: pack all four quadrants, then systematically remove packs to identify and control bleeding sources. Next control contamination by clamping or stapling injured bowel. Then perform a thorough, systematic exploration of all four quadrants, lesser sac, retroperitoneum, and pelvis. A LLQ stab can injure small bowel, sigmoid/left colon, iliac vessels, ureter, or bladder—all must be assessed.

You find a through-and-through sigmoid colon injury with gross fecal contamination and the patient remains hypothermic, acidotic, and coagulopathic. What do you do?

Expected answer

This is the lethal triad—convert to damage control. Control contamination by resecting or stapling off the injured segment and leaving the bowel in discontinuity, pack for hemostasis, place a temporary abdominal closure (vacuum dressing), and return to the ICU to correct hypothermia, acidosis, and coagulopathy. Re-explore in 24–48 hours for definitive repair and decisions about anastomosis versus colostomy once physiology is restored.

If the patient is stable and you find an isolated small bowel laceration with minimal contamination, how do you manage it?

Expected answer

Primary repair if the defect involves less than ~50% of the circumference and the bowel is viable, using a transverse closure to avoid stenosis. For larger injuries, devascularization, or multiple closely spaced injuries, perform segmental resection with primary anastomosis in a stable, adequately resuscitated patient.

How do you evaluate and manage a possible retroperitoneal or ureteral injury from a LLQ stab wound?

Expected answer

Inspect the left colon mesentery and retroperitoneum; a penetrating (zone 2/3) hematoma in the setting of penetrating trauma generally must be explored. Trace the ureter and look for urine extravasation; give IV methylene blue or indigo carmine if uncertain. Repair ureteral injuries primarily over a stent with a tension-free spatulated anastomosis. Inspect the bladder and repair intraperitoneal bladder injuries in two layers with postoperative catheter drainage.

What antibiotic and tetanus considerations apply?

Expected answer

Give preoperative broad-spectrum antibiotics covering gram-negatives and anaerobes (e.g., a second-generation cephalosporin or equivalent) before incision for penetrating abdominal trauma; continue 24 hours if no hollow viscus injury, and extend for established contamination. Update tetanus prophylaxis based on immunization status.

What postoperative complications do you anticipate after this trauma laparotomy?

Expected answer

Anticipate surgical site infection and intra-abdominal abscess (especially with colonic injury), anastomotic leak, enterocutaneous fistula, abdominal compartment syndrome (monitor bladder pressures, especially with packing or large-volume resuscitation), missed injury, ileus, and venous thromboembolism. Maintain a high index of suspicion and low threshold for re-imaging or re-exploration if the patient fails to improve.