Gunshot wounds of the abdominal aorta

Gunshot

Wounds

of the Abdominal

Aorta

CHARLES H. MANLOVE, JR., M.D., FRANK W. QUATTLEBAUM, M.D., ROBERT S. FLOM, M.D. AND JAMES W. LAFAVE, M.D., St. Paul, Minnesota From tbe Surgical Service, Ancker Hospital, St. Paul, Minnesota; and tbe Department of Surgery, University of Minnesota, Minneapolis, Minnesota.

UNSHOT wounds of the abdomen are usuaIIy fraught with serious consequences and not infrequentIy are fatal. To say the least they are very dramatic, and such an injury can cause near panic in an emergency room which is unaccustomed to such lesions. It is fortunate that most general hospitaIs in large cities are equipped and have personne1 trained to dea1 with such emergencies. In some of these injuries there is littIe, if anything, that can be done to save the Iife of the patient because of extensive damage to the invoIved structures. The patients who die shortIy after being injured and before proper medica aid can be given usuaIly die from exsanguination. Death occurring at a later time may be due to complications such as peritonitis, septicemia, puImonary embolism, pneumonia, or uremia. Patients with gunshot wounds of the abdomina1 aorta frequentIy die. However, there are a few reported cases of survival folIowing such an injury. Undoubtedly, countIess deaths can be attributed to this injury during miIitary combat. Such wounds seldom occur in civilian life, but when seen are usuaIIy a resuIt of hunting accidents, hoIdups, or argumentation. LaRoque [2] reported a very unusua1 case in 1926 in which a buIIet penetrated one waI1 of the abdominal aorta with insuffIcient force to come out the other wall. The buIIet was then carried in the bIood stream as an emboIus which became lodged in the femoral artery. This patient had the bullet removed and survived both initia1 injury and embolectomy. Theodor BiIIroth [I] in 1859 wrote an interesting treatise on the treatment of gunshot wounds which dealt with dkbridement, remova1 of the buIIet and amputation. It was not until recently with the advent of modern

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surgicaI advances that a positive attack couId be made successfuIIy in the treatment of these injuries. Some of the more important aspects of modern surgica1 therapy incIude the foIIowing: (I) good anesthetic technics; (2) proper and adequate treatment of shock, including massive whole blood transfusions; (3) rapid transportation to the hospita1; (4) correct and prompt evaIuation of the condition; (5) antibiotics; (6) good surgical vascuIar technics; and (7) proper postoperative care. Moore et al. [4] had pubIished in 1954 an exceIIent paper on gunshot wounds of major arteries. After much experimenta work on dogs, they pointed out a number of important facts: (I) gross intimal damage usuaIIy exceeds the apparent externa1 damage, (2) closure of arterial defects in the IongitudinaI direction aImost aIways causes undesirabIe narrowing of the Iumen, (3) transverse closure aImost aIways results in a distortion of the Iine of bIood Aow and may produce a thrombosis, (4) it is better to resect the injured segment and perform primary anastomosis with or without the aid of a graft, depending upon how easiIy the ends of the vesse1 can be approximated without tension. Such advice is sound and must certainIy be considered when dealing with injuries to Iarge vesseIs. However, when a vesse1 the size of the abdominal aorta is involved it may be possibIe to treat it satisfactorily in a different manner. Each case has to be given individual consideration depending upon the extent of the damage inflicted. Primary repair of a vesse1 the size of the abdomina1 aorta, in either a IongitudinaI or transverse direction, is feasibIe since the Iumen is Iarge enough that such a distortion would be minima1 or of no clinica significance. This is particuIarIy true in younger persons whose vesseIs are elastic and have the abiIity to stretch sIightIy and still function normaIIy. The deveIopment of a pre- or poststenotic American

Journal

o/ Surgery,

Volume

gg. June,

1960

Manlove,

QuattIebaum,

aneurysm is a comphcation which must be considered in primary repair of a gunshot wound of the abdomina1 aorta, and such a complication would be more Iikely to occur in cases when surgica1 repair produces a significant stenosis. In younger persons, whose vessels are more elastic, such complications should be seen Iess frequently. ObviousIy, the size of the missiIe penetrating the vesse1 waI1 will greatIy determine the extent of damage done. If there is any doubt that a stenosis is present foIIowing the surgica1 correction of such a Iesion, it is best to resect the entire area invoIved. Then primary end-to-end anastomosis can be performed, or if the gap is too great, an aortic homograft or avaiIabIe synthetic prostheses can be inserted. The foIIowing case of gunshot wound of the abdomina1 aorta is reported because it presents a number of interesting aspects in the earIy and Iate treatment of such an injury. CASE

REPORT

At IO: IO A.M. on September 20, 1958, a thirtyone year oId white man received a gunshot wound of the abdomen and Ieft wrist during an argument. The buIIets were fired at point bIank range from a .25 caliber pisto1. He was brought to Ancker HospitaI at IO: 25 A.M. and was found to be in deep shock. Powder burns were present, around the buIIet wound which was just above and to the right of the umbiIicus. There was aIso a through-and-through buIIet wound of the Ieft wrist. PhysicaI examination reveaIed a we11 developed, moderately obese man in acute abdomina1 distress. He was paIe and perspiring profuseIy, but was we11 oriented. BIood pressure was 55/40 mm. Hg.; puIse, 160 per minute; and respirations, 24 per minute. The skin was coId and cIammy. AuscuItation and percussion of the chest reveaIed nothing of note except a tachycardia. The abdomen was tense, tender and rigid in a11 quadrants, and no abnorma1 masses could be detected. No bowe1 sounds couId be heard, and there was no wound of exit for the missiIe which entered the abdomen. Examination of the extremities reveaIed a buIIet wound of the Ieft wrist. No sensory, motor or vascular changes were noted in the upper or Iower extremities. PuIses were present in the femoral, popIitea1 and dorsa1 pedis arteries of both Iegs. Within ten minutes after arriving at the hospita1, bIood was drawn for type and crossmatching. A poIyethyIene tube was inserted into the saphenous vein in the Ieft ankIe and a unit of 0 negative blood was started. The patient was in the operating room at 10:40 A.M. which was fifteen minutes after admission to the hospita1 and thirty minutes after 942

FIom and LaFave injury. Another “cut down” was pIaced in the right ankIe, and whiIe the abdomen was quickIy shaved and prepared, blood was administered under pressure so that a reading of 120/80 mm. Hg was obtained. Less than an hour after the patient’s admission to the hospital, Iaparotomy was begun with the patient under IocaI anesthesia, using a right paramedian incision. During this time the patient was first intubated and then given PentothaI,@ nitrous oxide, oxygen and anectine throughout the remainder of the procedure. When the peritoneal cavity was opened, about 250 cc. of free bIood was found. There was an enormous retroperitonea1 hematoma, but no active bIeeding was apparent. The missiIe had passed through the stomach, entering the anterior wail near the Iesser curvature and exiting through the posterior waI1. There appeared to be powder burns on the serosa of the stomach surrounding the wound of entrance. This area was excised and the anterior stomach waI1 closed with an inner row of No. 3-o chromic catgut and an outer row of No. 4-o silk sutures. The wound in the posteroir wall was simiIarIy cIosed. The path of the missile was traced posteriorIy and found to go through the mesenteries of the transverse coIon and smaI1 bowe1. A Iarge branch of the superior mesenteric vein was found to be lacerated and was repaired with No. 5-o

arterial siIk so that the lumen was patent. Further bIeeding was present in this area but since the source couId not be readiIy Iocated, it was controIIed temporariIy with packing. The path of the missiIe was then seen to enter the retroperitonea1 hematoma. (Fig. I .) This was opened wideIy to the Ieft of the root of the smaI1 bowe1 mesentery and profuse bIeeding occurred. It was soon apparent that there was a hoIe in the abdomina1 aorta about 4 cm. proxima1 to the bifurcation. BIeeding could not be controIIed unti1 Pott’s clamps were appIied to the aorta above and beIow the buIIet wound. A through-and-through wound of the aorta was then noted. The wound of entrance was approximately 6 mm. in diameter, and the wound of exit approximateIy 20 mm. in diameter. Because of the eIasticity of the patient’s aorta, it was beIieved that both wounds shouId be cIosed primariIy with running No. 5-o siIk sutures. This was performed, and IittIe, if any, narrowing of the diameter of the vesse1 was noted. The anterior wound was cIosed IongitudinaIIy and the posterior wound transversly, the latter being accompIished with moderate diffIcuIty because of its Iocation. The pack which had previousIy been pIaced on the root of the mesentery was removed and a severed branch of the superior mesenteric artery was found and temporarily occIuded. Since there was no obvious interference with the bIood suppIy to the smaI1 bowe1, this vesse1 was then tied.

Gunshot Wounds of AbdominaI Aorta

FIG. I. Diagrammatic sketch of the path of the bullet as it passed through the stomach, mesenteries of the transverse colon and small bowel, and aorta. It passed to the Ieft of the vertebral column and lodged beneath the skin of the

back.

The srnaI1 bowel was thoroughIy examined and the third portion of the duodenum was found to be grazed, with intact mucosa protrud~ug~through the seromuscuIar tear. This was repaired with No. 4-o silk.A fina inspection revealed nothing further, and the abdominal incision was cIosed in layers. At the compIetion of the procedure, the patient’s blood pressure was rgo/~ro mm. Hg; pulse, tr8 per minute; and respirations, 24 per minute. The pulse was strong in both Iegs. During the procedure he received a total of 14 pints of blood, 500 cc. of plasma and 8 gm, of calcium. The patient’s postoperative course was febrile for thirteen days, temperature usually about LOI’ ta 102'F., and during this time atelectasis and pneumonia of the Iower iobe of the right lung developed. Severe ileus also developed which relented on the eighth day after surgery. His respiratory problem cIeared up with conservative treatment and the administration of antibiotics ~Chioromycetin~ and penicillin).

On the ninth postoperative day, the buIIet became palpable beneath the skin in the Ieft flank close to the paraspinous muscles. IL was removed with the patient under Iocal anesthesia. He was discharged twenty-one days after admission clinically well and eating without difftcu1t.y. He lost zs pounds in weight during this time. On the thirty-eighth postoperative day the patient was readmitted to the hospital with a small subcutaneous abscess under the superior portion of the abdominal incision. This was incised and drained. Culture showed a hemolytic variety of StaphyIococcus aureus. The wound was treated with hot moist packs and antibiotics were administered, and the patient was discharged five days Iater with a clean, granu~at~ng wound. He was next admitted on the fifty-eighth postoperative day. The previous incision and drainage site had healed, but an extensive abscess was now present about the site of entrance of the abdominal bullet wound, He was first treated with hot packs,

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ManIove,

QuattIebaum,

FIom

Albamycinm was administered, and then, with the patient under general anesthesia, the abscess was incised and drained. At this time, the buIlet tract involving the skin and subcutaneous tissue was excised. Recovery folIowing this procedure was uneventful. When the patient was Iast seen in the outpatient department one hundred and two days after original injury, the wounds were well healed and he was feeIing fine. His appetite was exceIIent, he was fast regaining the lost weight, and had no circuIatory diffrcuIties.

and

LaFave

A primary end-to-end anastomosis may be accomplished if tension at the suture Iine is minimaI. ShouId the tension be too great, a prosthesis should be inserted to restore continuity. A case report of a gunshot wound of the abdomina1 aorta is incIuded. REFERENCES

I. BILLROTH, T. Historical studies on the nature and treatment of gunshot wounds from the fifteenth century to the present time. Berlin, 1859. Translated by Rhoads, C. P. Yale J. Biol. 0 Med., 4: 16, ‘931. 2. LAROOUE. G. P. Penetrating bullet wound of the thoracic aorta followed byjodgment of the bullet in the femoral artery. Ann. Surg., 83: 827, 1926. 3. MOORE, H. G., JR., NYHUS, L. M., KANAR, E. A. and HARKINS, H. N. PreIiminary experimental observation of the nature, extent, and repair of gunshot injuries of the aorta. West. J. Surg.. 61: 607, rgi3. 4. MOORE, H. G., JR., NYHUS, L. M., KANAR, E. A. and HARKINS, H. N. Gunshot wounds of major arteries. Surg.: Gynec. ~ZYObst., 98: rzg, 1954.

SUMMARY

Some patients survive gunshot wounds of major blood vesseIs in&ding the aorta Iong enough to reach the hospitaI. Prompt recognition and diagnosis of such injuries is essential to proper therapy. Wounds of major vesseIs incIuding the aorta may be sutured primariIy; but if there is appreciable evidence of stenosis foIIowing such a procedure, the traumatized area should be resected.

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