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History
A 22-year-old man presented to the trauma center with a single gunshot wound to the right upper quadrant. The patient’s systolic blood pressure was reported to be 80 mm Hg in the field.
Examination
The patient was alert and responsive on arrival. His initial vital signs were a heart rate of 120 beats per minute, a systolic blood pressure of 138 mm Hg, and a respiratory rate of 20/min. His abdominal examination was significant for a gunshot wound approximately 10 cm inferior to the right costal margin and 6 cm lateral to the midline. In addition, his abdomen was distended and diffusely tender to palpation.
Management
After blood was drawn for type and cross-match, the patient was moved to the operating room. A massive transfusion protocol was initiated, and a cephalosporin antibiotic was administered. After intubation, a midline exploratory laparotomy was performed. A significant hemoperitoneum was evacuated. At this point, the anesthesiologist stated that the patient’s systolic blood pressure had dropped to 80 mm Hg. On rapid inspection of the abdominal cavity, through-and-through wounds to the prepyloric gastric antrum, through-and-through wounds to the head of the pancreas, and a large midline supramesocolic hematoma were noted. Division of the gastrocolic omentum allowed for exposure and suture repair of the anterior and posterior holes in the prepyloric antrum. A few peripancreatic bleeders were ligated as the head of the pancreas was inspected. The location of the through-and-through wounds in the head of the pancreas suggested that neither the common bile duct nor the main pancreatic duct of Wirsung was injured.
Question
The most appropriate next step at operation is:
Left anterolateral thoracotomy/cross-clamp descending thoracic aorta
Add median sternotomy to midline laparotomy incision
Left medial mobilization maneuver
Cattell-Braasch maneuver
Management
At this point, the midline supramesocolic hematoma was larger than when first observed. It was approached by a left medial mobilization maneuver …