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Management specificities for abdominal, pelvic and vascular penetrating trauma
Journal of Visceral Surgery (2017) 154, S43—S55
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REVIEW
Management specificities for abdominal, pelvic and vascular penetrating trauma E. Hornez a,1, F. Béranger b,1, T. Monchal c,1, Y. Baudouin a, G. Boddaert d, H. De Lesquen b, S. Bourgouin c, Y. Goudard e, B. Malgras f, G. Pauleau e, V. Reslinger a, N. Mocellin a, C. Natale b, L. Meyrat b, J.-P. Avaro b,g, P. Balandraud c,g, S. Gaujoux h, S. Bonnet a,g,∗ a
Service de chirurgie viscérale et générale, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France b Service de chirurgie thoracique et vasculaire, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France c Service de chirurgie viscérale, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France d Service de chirurgie thoracique et vasculaire, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France e Service de chirurgie digestive, endocrinienne et métabolique, HIA Laveran, 13013 Marseille, France f Service de chirurgie viscérale, hôpital d’instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France g École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France h Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France Available online 26 November 2017
KEYWORDS Ballistic penetrating trauma; Damage control surgery
Summary Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient’s hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial
∗ Corresponding author at: Service de chirurgie viscérale et générale, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France. E-mail address: [email protected] (S. Bonnet). 1 These authors have contributed equally to this article.
https://doi.org/10.1016/j.jviscsurg.2017.10.009 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
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Packing; Vascular shunt; Multi-disciplinary approach; Hemostasis
E. Hornez et al. laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles. © 2017 Elsevier Masson SAS. All rights reserved.
Introduction Wartime wounds are typically penetrating injuries caused by bullets or flying debris. Abdominal wounds, generally of hollow organs, are most often multiple (4 to 5 per patient in recent combats) and represent between 10% and 20% of warfare wounds [1,2]. Truncal trauma, representing nearly half of preventable deaths, accounts for 20 to 30% of all deaths in warfare settings. Retroperitoneal organ involvement is more rare but severe. Ballistic injury to central great vessels (aorta, inferior vena cava and mesenteric vessels) is often associated with multiple and/or extensive other abdominal injuries. Pelvic wounds are severe, with mortality exceeding 30% when the rectum is involved [1]. Vascular injuries are prevalent and most concern limb injuries. Borderline compartment injuries are defined as penetrating trauma of frontier zones between two compartments (cervicothoracic, axillary, thoraco-abdominal and inguinal); they are characterized by frequent bleeding, anatomical complexity, difficulty in approach and surgical strategy. Complementary laboratory and imaging investigations are not very sensitive, and most often assessment of lesions is made during surgical exploration in the context of damage control. In the unstable patient, the goal of management is to obtain rapid hemostasis and hemodynamic stability to save the life of the wounded patient. If the patient is hemodynamically stable, the goal of management is first to correctly assess all injuries in order to perform the appropriate treatment urgently. The goal of this chapter is recall the specificities of the diagnostic and therapeutic management of patients sustaining penetrating trauma to the abdomen, pelvis, vessels and bordering compartments in the context of civilian warfare attacks and massive afflux of wounded.
Surgical approaches Laparotomy is a ‘‘crash-laparotomy’’, the incision is made with a cold blade scalpel. The patient is in shock; because of peripheral vaso-constriction, there is no worrisome bleeding during laparotomy and use of electrocautery is a loss of time. The laparotomy is on the midline.
Treatment of hemorrhage and contamination Rapid control of major bleeding In case of massive bleeding, the first gesture is manual compression of the abdominal aorta just below the diaphragm. The anesthesiologist can attest to the efficacy of the procedure when the arterial pressure rises. Manual compression can be replaced by supra-celiac cross clamping, after finger dissection of the muscular fibers of the crura. Simultaneously, the hemoperitoneum is rapidly evacuated with traditional and autologous blood recovery system suction. While in blunt trauma, pads are added in each quadrant to identify the origin of bleeding, the source of bleeding from ballistic wounds is much easier by the more localized nature of bleeding that can most often be controlled manually. A simple measure is to compress the mesenteric root between the thumb and index (Fig. 1). Once this compression is done, the two peritoneal sides can be incised and hemorrhage can be selectively controlled. If this is not possible, and in particular, when the superior mesentery artery is involved, hemorrhage control may require medial rotation of the viscera: • either from the right: Kocher maneuver followed by mesenteric disinsertion (Cattell and Braasch maneuver) (Fig. 2); • or from the left: left medial rotation of colon, spleen and pancreatic tail (Mattox maneuver) (Fig. 3).
Analytic treatment of hemorrhagic injuries
Abdominal wound specificities Hemodynamically unstable patient Principles Bleeding originating from solid organs is treated by resection (splenectomy, nephrectomy) or compression (peri-hepatic or retroperitoneal packing). Hollow organ injury is controlled by temporary measures: linear stapling. There is no place for stoma creation in the unstable patient. The main goal is only to stop peritoneal contamination.
Splenic injury should be treated by splenectomy according to the medial rotation technique. To control bleeding from the spleen rapidly, the spleen is pushed up on the spine and the posterior mesogastrium is opened until the spleno-pancreatic block is elevated into the midline, allowing approach to the splenic pedicle to control the bleeding. Liver hemorrhage is treated essentially by peri-hepatic packing (PHP). This procedure should be performed methodologically according to the instructions in the technical factsheet. If liver bleeding is intra-parenchymal, not rare when projectiles penetrate through the liver, ‘‘internal’’ packing can be achieved with a Penrose drain ligated at one extremity, or a Sengstaken—Blakemore tube, or even
Management specificities for abdominal, pelvic and vascular penetrating trauma
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Figure 1. Compression of the root of the mesentery between thumb and index fingers.
a finger of a surgical glove filled with saline (Fig. 4). Last, hemorrhage that persists in spite of initial packing requires revision of the original packing. If bleeding persists in spite of PHP that seems to be ‘‘well placed’’, arterial bleeding should be suspected and elective intra-fascial ligation of the hepatic artery should be entertained, taking care to place the ligation distal to the gastroduodenal artery take-off. Retroperitoneal hemorrhage or hematomas (RPH) can be central (aorta and vena cava), lateral (kidneys) or pelvic (pelvic fracture). Central RPH should be explored routinely. Before exploration, however, the supra-celiac aorta must be controlled. The retroperitoneum cannot be explored entirely by a single approach: either the Cattell and Braasch or the Mattox maneuver must be performed according to whether the surgeon needs to control the vena cava or the aorta, respectively. Lateral RPH requires exploration only if expanding or if the peritoneum has been violated but there is no active bleeding. Pelvic RPH requires extra-peritoneal packing.
Coprostasis or enterostasis This consists in closing gastro-intestinal defects with mechanical staplers, with no attempt to restore gastrointestinal continuity: this can be done at a later stage. If mechanical staplers are not available, the wounded intestinal segment can be tied off with vascular tapes or other means of ligation.
Hemodynamically stable or stabilized patient Principles In this setting, the lesions are usually mainly gastrointestinal, with little or no hemorrhage. However, the duration of operation should not exceed 60—90 minutes
Figure 2. Cattell and Braasch’s maneuver: right visceral rotation with extended duodenopancreatic mobilization followed by disinsertion of the mesenteric root.
to avoid the onset of post-traumatic coagulopathy, forerunner of the lethal triad (coagulopathy, acidosis and hypothermia). Here again, methodical exploration should precede repair(s). Exploration should proceed in the craniocaudal direction, starting with the abdominal esophagus and ending with the rectum. The pitfalls are areas that are not accessible without specific maneuvers: the esophagogastric junction, the posterior aspect of the stomach,
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Analytic treatment of lesions Duodenum Duodenal injuries occur in about 10% of warfare victims. Their severity is related to associated injuries and the chemical toxicity of duodenal secretions [3]. More than 50% involve the second portion of the duodenum. Their diagnosis is not always obvious and treatment after delayed diagnosis can be most difficult. The 3 B rule merits to be known: Bile leakage, presence of air-filled Blebs, and Blood in the form of peri-duodenal hematoma. The presence of even one ‘‘B’’ calls for compete exploration of the duodenum, requiring a Kocher maneuver. The choice of treatment should take into consideration the size of the wound (in relation to the circumference of the duodenal lumen), the location (in relation to he papilla) and associated lesions. Treatment consists of simple duodenorrhaphy, duodeno-jejunostomy or drainage.
Duodenorraphy Simple duodenorraphy is possible if the resultant stenosis of the duodenal lumen is less than 50%.
Duodeno-jejunostomy
Figure 3. Mattox’ maneuver: left visceral rotation with mesogastric dissection and medialization of the spleen and pancreas.
Figure 4. saline.
‘‘Internal packing’’ with a glove finger filled with
the duodeno-jejunal junction, the mesenteric border of the small intestines, the mesocolic border of the transverse colon and the affixed aspects of the colon. Repair techniques should be adapted to the injured organ. The stomach and the small intestines are not at all problematic, since most are amenable to debridement-suture closure or resection-anastomosis, realizing that the only limitation is the remnant length. The gastro-intestinal segments that pose the most difficult problems are the duodenum and the colon. The surgical approaches are not any different from those used for the unstable patient.
When the wound involves more than 50% of the duodenal circumference, and in particular when the second portion is involved, there are several options, including side-to-end Roux-en Y duodeno-jejunostomy, jejunal patch or duodenal derivation. These techniques are reserved for destructive wounds, especially combined duodenal and pancreatic lesions where the probability of suture repair failure is high. The common point is that they divert the alimentary flow from the repair. Such diversions can consist of simple pyloric exclusion associated with gastro-jejunostomy or a tube duodenostomy. Pyloric exclusion is simple to perform, and the diversion is reversible. The pylorus is closed either by endolumenal sutures inserted through a gastrotomy, or extra-lumenal mechanical suture without division. Whatever the technique, exclusion is completed by a gastro-jejunostomy. The pylorus opens up spontaneously within two to three weeks in 90% of patients. The main disadvantage is the possibility of marginal peptic ulcer at the level of the gastro-jejunostomy. The second disadvantage is that some duodenal fistulas can occur after three weeks [3], when the pylorus might be patent. Tube ‘‘duodenostomy’’ consists in duodenal repair and placement of two jejunostomies and one gastrostomy: • the first jejunostomy is retrograde, and ‘‘decompresses’’ the repair; • the second jejunostomy is downstream, and is used for feeding; • the third tube is a gastrostomy placed upstream from repair, the goal of which is to divert the gastric juices. This tube can be placed through the pylorus and then becomes a gastro-duodenostomy.
Drainage The use of diverting techniques has recently been called into question [4]. Another option, particularly when the wound is heavily damaged or seen at a late stage, could be to insert a Levy ‘‘spiral’’ drain after debridement of the wound edges [5]. This device is comprised of a suction system coupled with an irrigation system, destined to neutralize the duodenal content that always seems to seep around the drain.
Pancreas Just as for duodenal wounds, a suspected pancreatic wound calls for careful exploration also requiring a Kocher
Management specificities for abdominal, pelvic and vascular penetrating trauma maneuver combined with division of the gastro-colic ligament. Wide drainage is essential, using irrigation-drainage modules. The only indications for resection are when the main pancreatic duct is wounded to the left of the isthmus, which should be treated by distal pancreatectomy. Transection of the main duct to the right of the isthmus should be drained; duodeno-pancreatectomy is proscribed in this context.
Colon Left colon The dogma is to divert all ballistic wounds of the left colon [6]. In practical terms, ‘‘colonic diversion’’, in the broadest sense of the term, can consist of: • exteriorization of a small wound, easily brought out through the abdominal wall (typically small wounds of the sigmoid or transverse colons); • suture repair ‘‘protected’’ by an upstream colostomy, if the wound is located in a fixed segment (hepatic or splenic flexure, rectum); • extended resection without anastomosis. The distal stump is closed and left in the abdomen while the proximal segment is brought out through the abdominal wall (a typical Hartmann procedure for extended wounds of the sigmoid colon).
Right colon Right colonic wounds can be treated by simple suture repair or resection-anastomosis, but once again, if there is any doubt as to a difficult postoperative course (exsanguinated patient, multiple lesions), a diversion should be envisioned (ileostomy rather than cecostomy).
Transverse colon Transverse colonic wounds are often considered as rightsided wounds, however with a ‘‘better’’ prognosis, that are potentially amenable to single stage treatment. In fact, these are usually severe lesions, not in themselves, but because of the frequent association with lesions of the pancreas, spleen, or stomach due to the central location of the ballistic wound. The high rate of anastomotic fistula after primary repair makes this approach prohibitive in certain series (around 25%) meaning that good judgment should guide the surgeon’s attitude more than dogma.
Specificities for management of pelvic wounds Initial management Pelvic wounds are defined by lesions that extend beyond the bony framework and can involve pelvic contents, vessels, intestinal or urinary tract. The initial step is to examine the patient supine and completely undressed. The surgeon looks for wounds and contusions, making sure to examine the back, the buttocks and the perineum. Ballistic impacts and orifices are examined for leakage of blood, feces or urine. Digital investigation is important to evaluate the position of the prostate and the tonicity of the sphincters (in the conscious patient). In this context, blood in the rectal ampulla is considered evidence of a colonic wound until proven otherwise. Blood in the urine (hematuria or uretrorrhagia) attests to injury of the urinary tract. Insertion of a bladder catheter is contraindicated in the presence of uretrorrhagia or suspicion of urethral injury. The examiner must check for femoral pulse
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and potential vascular, nervous, bony injuries (palpation of the pelvis) or a hip joint problem. A pelvic X-ray may indicate bone fracture or the presence of a projectile. Extended Focused Assessment with Sonography for Trauma (eFAST) is performed in the emergency bay to search for abdominal fluid. If the patient is hemodynamically stable, a total body CT scan is performed to complete the initial workup and this investigation has a good sensitivity and specificity to analyze the missile trajectory.
Hemodynamically unstable patient Management of in-extremis patients, who are initially nonstabilized with refractory hemorrhagic shock, imposes the need for rapid decisions and aggressive damage control maneuvers, as described. In patients who are unstable despite initial resuscitative measures, hemostatic maneuvers depend on the results of the eFAST investigation.
Negative eFAST If the eFAST is negative, the bleeding is from the pelvis alone and, in this case, the therapeutic possibilities are extraperitoneal packing (EPP) performed a soon as possible in the emergency bay [7] to effectively control venous bleeding, and, according to local expertise, insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) [8] to stabilize the patient until arterial embolization or arterial covered stent insertion can be performed.
Extra-peritoneal packing (EPP) EPP is performed in the supine patient under general anesthesia. An 8 cm suprapubic midline incision is performed, the linea alba is opened. The peritoneum is displaced cephalad, taking care not to open it. This is of capital importance because an intact peritoneum is necessary to assure most of the counter-pressure of the packing. This maneuver allows access to the anterior aspect of the bladder and the subperitoneal hematoma, which is usually under some pressure. Blood clots are removed digitally, and laparotomy pads are inserted one after the other into the lateral rectal spaces of Retzius and Bogros. Improvement of arterial pressure should be immediate with an increase of 20 to 30 mmHg. Afterwards, only the skin is closed with staples and a pelvic compressive wrap is placed and tightened to reduce the pelvic volume as much as possible.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Intra-aortic balloon occlusion is an alternative to surgical cross clamping of the aorta and allows control of infra-diaphragmatic arterial bleeding while favoring redistribution of circulating blood volume to the heart and brain. The REBOA is inserted via a surgical approach to the common femoral artery that is punctured under direct vision. The balloon should be inflated below the renal arteries. An improvement in blood pressure should be immediate.
Arteriography Therapeutic arteriography is part of radiologic damage control. It allows selective embolization of injured arteries while respecting the surrounding tissues and the pressure within the retroperitoneal hematoma, which favors spontaneous hemostasis. In patients with catastrophic bleeding, it may be necessary to perform more proximal embolization, at the level of the internal iliac artery [9]. For hemorrhage originating from the common or external iliac artery, insertion of a coated stent may be envisioned.
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Positive eFAST If eFAST is positive, abdomino-pelvic damage control should be performed (only the specificities of the pelvic component are dealt with in this paragraph) starting with a xipho-pubic midline laparotomy. The pelvis is packed, which often allows temporary hemostasis. The pads are then removed to determine the lesions. Management then depends on the origin of the bleeding: • arterial bleeding coming from the mesorectum or the bladder is an indication for directed hemostasis by Vicryl 2.0 suture ligatures; • for arterial bleeding, proximal control is obtained at the level of the infrarenal aorta or common iliac while distal control is obtained at the level of the external iliac artery. If arterial bleeding is coming from the internal iliac, proximal ligation is indicated, sometimes bilaterally. In case if injury to the common or external iliac artery, the vessel should be suture repaired, if possible; if not, a temporary vascular shunt should be inserted. Simple ligation at this level leads to lower limb ischemia in 50% of patients and therefore a femoro-femoral cross-over bypass should be performed; • in case of venous hemorrhage, temporary control can be obtained by direct compression with swabs on-a-stick. In case of injury to the common or external iliac vein, simple suture repair can be performed if possible; if not ligation is the rule. When the origin of bleeding is deep, intraperitoneal pelvic packing is performed by insertion of pads into the latero-rectal fossa and behind the bladder. The pressure of the packing should be sufficient to compress the venous structures against the bone.
Hemodynamically stable or stabilized patient Rectal injury Surgical management proceeds in three steps: initial perineal examination under general anesthesia; second, abdominal diagnosis via an exploratory laparotomy which allows treatment of lesions and routine colostomy; and third, perineal therapy to treat the perineal injuries and drain the cellular spaces. Management can be summarized by the 4 D’s: drainage, diversion, distal wash-out and damage repair.
First step: perineal examination under general anesthesia Anoscopy should be performed with precaution: submucosal hematoma attests indirectly to sphincteric injury. Direct repair should be envisioned whenever possible, either transanally for distal lesions, or through the wound itself, for destructive penetrating trauma by projectile.
Figure 5. space.
Drainage of both ischio-rectal fossa and the presacral
• the rectal wound is destructive: a Hartmann resection is necessary. The operative strategy can be simplified whenever necessary by simple staple closure of the sigmoid, without any stoma, to exclude the rectum and decrease distal contamination. The staple line should be at the level of the sigmoid loop and will become the distal stump for later reconstruction. Last three steps: debridement, drainage, distal lavage. The last and third step, performed through a perineal approach, includes wide debridement of the missile tracts and orifices with counter incisions. The ischio-rectal fossae are drained routinely (Fig. 5) [10]. The para-rectal spaces are opened lateral to the rectum, at 3 and 6 o’clock, between the palpable external sphincter and the ischium. The subcutaneous tissues are then opened with scissors or by finger dissection until reaching the ischio-rectal fossa. Lateral drainage should be extended until reaching the levators, felt by palpation. If the trajectory leads to suspicion of a sub-peritoneal rectal wound, or whenever a doubt persists as to this, the levator muscle can be divided to insert a Delbet type drain (corrugated sheet drain) in contact with the rectal wall. Drainage of the presacral space is not routine [11], but is necessary when the posterior aspect of the rectum is involved. This requires opening the presacral space by dividing the anococcygeal raphe. It is recommended to copiously lavage the space with a betadine solution before inserting the Delbet drains. Anal sphincter injuries should always be repaired as soon as possible, since secondary identification of the sphincter edges is often very difficult. Dissection should be limited in order to allow tension-free end-to-end suture repair whenever possible.
Second step: midline xipho-pubic laparotomy, colostomy
Urinary tract injury
Two scenarios are possible [6]: • the rectal wound is not destructive, often only subperitoneal, as suggested by the trajectory and the information gleaned from the initial perineal examination. The presence of hematoma or air bubbles under the peritoneum should lead to digital exploration through the hematoma or incision of the peritoneum to access the mesorectal planes. A rectal lesion can be either simply drained or repaired if possible. A terminalized lateral colostomy just proximal to the lesion should be the rule;
Bladder injuries require a wide, vertical cystotomy, allowing full inspection of the bladder wall and visualization of the ureteral orifices. Devitalized tissues are debrided, followed by watertight closure, with a single layer of Vicryl 0 that should not include the pre-vesical fatty tissues. The bladder is drained by a trans-urethral or suprapubic catheter [12]. If there is ureteral injury, immediate repair, which may be time-consuming, is not recommended. In case of partial ureteral rupture (less than 50% of the circumference), an 8 French catheter is inserted and secured to the ureter by a
Management specificities for abdominal, pelvic and vascular penetrating trauma Vicryl 2.0 tie, then exteriorized through the skin. In case of complete ureteral disruption, the ureter is ligated with nonabsorbable suture material and a percutaneous nephrostomy is performed.
Perineal vaginal or scrotal wounds Positive diagnosis is made by inspection of the perineum. During the first step of lesion workup, these wounds are simply debrided and dressed. Scrotal closure enhances testicular preservation.
Soft tissue and pelvic injuries Soft tissues are debrided at the level of the entry and exit orifices, as well as along the trajectory of the projectile. Devitalized tissues are excised and foreign bodies are removed. In case of bone injury, all bony splinters are removed. These wounds are often destructive. Repeated debridement may be necessary to evaluate the evolution of tissue viability, which can change over time. Wound care may be facilitated by negative pressure dressings. For penetrating trauma, bony injuries are usually nondisplaced or minimally so, and fractures are rarely unstable. When bony injuries are unstable, they require an external fixator or a pelvic clamp. For fractures of the proximal extremity of the femur or the acetabulum, trans-condylar traction is placed while awaiting definitive treatment.
Specificities of vascular injuries Clinical diagnosis and evaluation Clinical examination must be systematic, simple, rapid and efficient. It should be bilateral and comparative, searching for major and minor signs of arterial involvement. Major signs are active exteriorized hemorrhage, pulsatile hematoma, absence of distal pulses and signs of frank ischemia (6 ‘‘P’’’s ‘‘pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis’’). In these clinical situations, nothing should delay surgical management in the operating room. Diagnosis can sometimes be more difficult when signs of arterial involvement are less obvious, i.e., when minor signs are found such as asymmetrical pulses, diminished pulse, penetrating wound near a vascular structure, hematoma, or patient in shock. If the victim is stable, complementary investigations can then be performed: these include Doppler sonography to measure the intensity of arterial flow and detect a potential diminution of the arterial pressure index; an angio-CT scan can locate the vascular injury and detect lesions such as false aneurysms, ruptures, dissections and intramural hematoma; intraoperative ontable arteriography may be necessary to identify the lesions and control their repair.
Initial management Whenever possible in the management of severely bleeding victims, at least two operators enhances satisfactory progress of the operation and helps decrease the duration (ideally < 60 min). Three steps are essential: • control of exteriorized bleeding: placing a tourniquet just proximal to the injury or at the proximal end of the thigh or arm is effective in stopping the hemorrhage. If this is not possible (junctional areas where a tourniquet
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cannot be placed), the operative assistant must apply direct pressure on or just proximal to the arterial lesion. It is also possible to inflate a Foley catheter balloon inserted directly into the vascular wound; • reduction of long bone fracture allows, in certain cases, to decrease the bleeding and above all to restore distal flow; • rapid transfer to the operating room.
Surgical management Equipment must be adapted and specific for the vascular repair (microsurgery, atraumatic clamps). The patient should be perfectly positioned as in elective surgery using the same landmarks. Clamps should be wide-jawed and be adapted to use in the contralateral limb or the upper limb to gain access for a venous graft if necessary. The surgical approach should be large enough to permit optimal proximal and distal vascular control of other associated vessels.
Proximal and distal control To control bleeding, it is mandatory to access the vessel proximal to the injury. For proximal lower limb injury, the inguinal ligament may need to be divided while the assistant applies direct compression on the injury. A trans-iliac, transor retroperitoneal access to the common and/or external iliac artery is very effective to control these hemorrhages. For the brachial artery, proximal control is obtained in the delto-pectoral groove splitting the muscular fibers of the pectoralis major and dividing the pectoralis minor muscle while taking care to avoid injury to any nerve fibers of the brachial plexus. Lastly, control of the subclavian arteries is obtained via a sternotomy on the right, and antero-lateral 4th interspace thoracotomy on the left.
Arterial debridement Adequate arterial debridement is necessary to obtain healthy tissues for arterial repair. Effectively there is a risk of early loss of patency if repair is performed in injured areas (intimal dissection, sub-intimal hematoma).
Proximal and distal thrombectomy After obtaining proximal and distal control and after debridement of the arterial edges, a Fogarty catheter is introduced routinely up and downstream to evacuate any potential thrombi (more often found distally).
Purging/rinsing of up and downstream arterial segments Cautious declamping, first upstream, then downstream purges the vessel. The lumen is then rinsed proximally and distally with heparin solution (12,500 to 25,000 UI/L).
Revascularization When a hospital is faced with a massive afflux of trauma victims, the duration of operation must be reduced to a minimum. Once the hemorrhage is controlled, the operators mush ensure definitive or temporary revascularization as possible. Only simple non-time-consuming vascular repairs should be undertaken. The reference technique, reversed saphenous vein bypass, [13] is not indicated in the damage control setting but will be performed later (24 h to 72 h) during the definitive vascular repair session. The suture
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E. Hornez et al. truncal and terminal arteries (Fig. 7) [16]. From the technical viewpoint particular to warfare surgery, arteries should be ligated at a distance from the trauma zone to avoid blowout of the stump in case of local infection.
Venous injuries
Figure 6.
®
Example of (Javid ) temporary vascular shunt.
material used must be adapted to the caliber of the vessel ® (double armed Prolene 5.0, 6.0 and 7.0 for the smallest vessel caliber). The type of repair depends on the degree of injury.
Whenever possible, particularly for large caliber veins such as the common femoral or iliac veins, direct venous repair or saphenous graft should be entertained to limit postoperative complications such as venous hypertension with edema. If complete (bypass) venous repair is envisioned, the artery too must be repaired to limit the duration of ischemia. If not, it is usual practice to treat the venous injury before the arterial injury, because treatment is most often simple (ligation), takes little time and favors arterial repair. Nonetheless, proximal and distal control can be intricate due to the existence of numerous venous collaterals and difficulty of dissection of these more fragile vessels. Occasionally it is useful to temporarily clamp the arterial inflow to decrease the venous return, facilitating venous hemostasis.
Direct lateral repair
Protection of vascular repair
This is adequate for small puncture wounds; caution must be exercised to avoid creating any stenosis.
Protection of vascular repairs is essential to limit the risk of sepsis and early anastomotic breakdown that can be lethal for the patient. This can be achieved by musculo-cutaneous flaps or more simply by negative pressure therapy with a specific interface to protect the vessels. When musculocutaneous destruction is massive and it is impossible to provide coverage, the bypass can be tunneled, as far as possible from the lesion, to limit sepsis involving the vascular repair.
Resection followed by end-to-end anastomosis This technique is used for transections with less than 2 cm loss of substance and is generally easily performed in young victims with healthy arteries after sufficient arterial debridement and mobilization. Nonetheless, a tension-free repair must be to ensure perfect postoperative patency. If the loss of substance is greater than 2 cm, temporary revascularization can be ensured by insertion of a temporary vascular shunt or a prosthetic repair with poly-tetra-fluoroethylene (PTFE) or Dacron graft.
Use of temporary vascular shunts (TVS) In the literature, this type of apparatus is used for rapid revascularization of extremities before definitive surgery in the following situations [14,15]: • saturation of health care facility by afflux of wounded; • severe patient status with hemorrhagic shock in the framework of surgical damage control; • open compound fracture requiring primary bone fixation. TVS is a reliable, easy and quick way to restore limb vascularization and patency can persist for up to 72 hours. The principle is to bypass the injured area by a supple, tubular structure between the downstream and upstream arterial (or venous) segments. There are several specific vascular shunts available on the market (Fig. 6), but, in the emergency setting, a tracheal suction tube, a Redon type drain, or any sort of drain adapted to the size of the vessel can suffice and assure temporary vascularization. Its placement is relatively easy, requiring local upstream and downstream heparinization, but, above all, it requires secure fixation to avoid untimely removal. If temporary revascularization is not possible (substantial loss of substance, shunt not available), definitive hemostasis should be obtained by arterial or venous ligation.
Arterial ligation Arterial ligation sacrificing the territorial vascularization of a portion of a limb is part of vascular damage control when hemorrhagic lesions are life-threatening. Debakey and Simeone published a list of arteries that can be ligated without major ischemia, making a differentiation between
Fasciotomies Definitive or temporary revascularization is usually never done immediately but rather four to six hours after the trauma. Because of this, it is imperative to prevent the onset of a compartment syndrome by performing routine fasciotomies (in the forearm essentially for the upper limb, and in the leg for the lower limb) (Fig. 8). These fasciotomies must be performed correctly and prophylactically at the very beginning of management [17].
Postoperative surveillance Initial surveillance is clinical, to assure that bleeding has completely stopped and that vascular repair is effective (peripheral pulses present). If this is not the case, the vascular repair has to be visualized by arteriography or angio-CT scan, or by repeat surgery.
Specificities in management of lower and upper anatomic borders of the trunk Adjacent compartment wounds (cervicothoracic, axillary, thoraco-abdominal and inguinal) present common features: hemorrhagic characteristic, anatomic complexity and difficulties in the surgical approach and strategy.
Cervicothoracic wounds Management in the emergency room Rapid examination of the patient is necessary to evaluate the usefulness of direct hemostasis. This can be
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Figure 7. List of arteries that can be ligated without major ischemic consequences. From DeBakey and Simeone, representing the percentage of amputation according to the vascular territory ligated.
obtained by a compressive dressing, or a large (at least 22 gauge) Foley catheter introduced through the wound and then maximally inflated and placed on continuous traction (Fig. 9) [18].
Management in the operating room Approach The neck, thorax and abdomen have to be prepped and draped. The surgical approach needs to be simple, wide and extended as needed. Initial sternotomy is clearly recommended because it allows access to the entire aortic arch. If cardiac arrest occurs, the initial approach should be an anterior clamshell bi-thoracotomy that allows first-line internal cardiac massage and clamping of the descending aorta. The incision can be extended by sternotomy for further hemostasis. Once the sternotomy has been performed, access to the aortic arch for temporary arterial hemostasis can be achieved by routine division of the left innominate vein. Venous injuries are initially controlled by packs or sponges on-a-stick. In case proximal control is necessary for one of the great vessels, a cervical or subclavicular extension can be made (with transection of the clavicle if necessary). The pleura should be opened routinely in order not to miss intrathoracic bleeding from the subclavian vessels.
Treatment Vascular injuries Arterial injuries include the common carotid, the subclavian and vertebral arteries. Carotid artery injuries warrant routine revascularization because of the poor prognosis associated with simple ligation [19]. There are however several situations that contraindicate revascularization, as summarized in Table 1. In some specific cases, temporary vascular shunts are recommended [15]. Common carotid reimplantations should be on the subclavian artery rather than the aortic arch. Emergency revascularization of the subclavian artery is not recommended [20]. The peri-scapular arterial anastomotic network is rich and acute ischemia occurs rarely. However, in the hemodynamically stable patient presenting with a bleeding subclavian artery injury distal to the take-off of the vertebral artery, revascularization is indicated, ideally by insertion of a TVS. Vertebral artery injury calls for simple ligation. For venous injury, the constraints are not as important. Most of the veins in this region can be ligated without the need of revascularization. Only bilateral internal jugular ligation is contra-indicated. Insertion of a large TVS is a satisfactory alternative to ligation.
Respiratory apparatus injury In case of tracheal destruction (rare in patients who survive), the tracheal intubation tube should be pushed beyond the
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Figure 8. Fasciotomy incisions for the upper and lower extremities: a: upper extremity: two incisions on the anterior and posterior surfaces of the forearm; b: lower extremity: opening of all four compartments through a single cutaneous incision on the lateral aspect of the lower leg.
Esophageal injury Ballistic wounds of the esophagus should be closed primarily [21] with full-thickness slowly absorbable or non-absorbable 3.0 sutures. Routine mediastinal drainage and nasogastric tube are indicated. A muscular flap (sterno-cleido-mastoid or intercostal) to cover the suture line is recommended in case of associated vascular injury. In case of loss of substance contra-indicating primary suture of the esophagus, closure over a large caliber T-tube is recommended. The extremity of the drain is exteriorized through a cervical contra-incision. Destructive wounds of the esophagus require exclusion by stapling the distal segment and left lateral cervical esophagostomy [21]. Mediastinal drainage is routine.
Axillary wounds Ballistic wounds in the axillary region include associated arterial, venous and brachial plexus injuries in one third of victims. In the larger series in the literature, fewer than 20% bleed and are hemodynamically unstable at initial management; fewer than 15% present acute upper limb ischemia [22]. Figure 9. Temporary hemostasis of a cervicothoracic wound. A large-bore Foley catheter is introduced directly through the wound orifice, inflated maximally, and then placed on traction. This results in compression of the vascular elements against the surrounding bony structures.
injury and inflated to ensure air-tightness. Wounds of the pulmonary apex require simple stapling or tractotomy, which assures hemostasis and aerostasis simultaneously. Thoracic drainage should be routine.
Surgical approach Draping should include the ipsilateral hemithorax, the entire upper limb and the thigh for eventual saphenous vein graft retrieval. The approach should allow proximal and distal control of the axillary artery. In the presence of expanding hematoma in the subclavicular and/or axillary hollow, it control the subclavian artery at its origin is strongly recommended before approaching the axillary artery. This control is obtained, on the right, by a midline sternotomy, and on the left by a 4th intercostal left anterior thoracotomy. The
Management specificities for abdominal, pelvic and vascular penetrating trauma Table 1
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Management of cervicothoracic vascular injuries in the context of damage control surgery. Action
Exceptions
Common carotid artery
Routine revascularization
Subclavian artery
Ligation
Ligation if: refractive SAP < 70 mmHg; areactive bilateral mydriasis; associated cranio-encephalic injury; associated destructive neck injury; absence of back flow Revascularization if: injury distal to the run-off of the vertebral artery in a stable patient
Vertebral artery Great mediastinal vein
Ligation Ligation
Revascularization if: bilateral internal jugular vein injury
SAP: systolic arterial pressure.
axillary artery is approached directly through the deltopectoral groove eventually extended along the arm medially. This requires routine division of the pectoralis minor insertion and incision of the pectoralis fascia. The insertion of the pectoralis major can be divided if necessary.
Treatment of lesions Once hemostasis has been accomplished by clamps, specialized vascular surgeons should be solicited (if management is in a trauma center). In their absence and if transfer of the patient is necessary, the general surgeon must adhere to damage Control principles as follows: • axillary artery wounds should be revascularized with a TVS; • venous injuries should be either ligated or shunted with a TVS; • brachial plexus wounds require simple landmarking of nerve roots (non-absorbable 3.0 monofilament) or therapeutic abstention; • soft tissue hemorrhage should be treated by packing, potentially with hemostatic compresses (e.g., ® QuickClot ).
Thoraco-abdominale injuries Thoraco-abdominal injuries (TAI) are defined by concomitant abdominal and thoracic compartment lesions associated with some degree of diaphragmatic injury. Such lesions are strongly suspected clinically when the entry orifice is located between the fourth costal interspace (nipple line in men) and the costal margin. Management of ballistic TAI requires a systematic approach because of its severity. Reported mortality ranges between 30 and 40% [23]. Management is resolutely surgical and non-operative treatment is exceptional. The surgical approach includes a laparotomy in more than 80% of cases, associated with thoracotomy in 15 to 30% of cases. When it is necessary to open both compartments, the reported mortality increases to 60% [23].
Emergency management Hemodynamically unstable patients should be managed immediately in the emergency room similarly to those with cervicothoracic wounds. It is however illusory to try to assure instrumental hemostasis. Bubbling or sucking wounds should be sealed by a dressing overlapping at least three ribs (Fig. 10) or an Asherman valve. Chest tube drainage should
Figure 10. Three-rib compressive dressing to occlude a sucking chest gunshot wound.
be routine in the presence of X-ray detected hemothorax or pneumothorax.
Operative room management The main difficulty here is to correctly choose the first compartment to open in order to obtain rapid hemostasis, while limiting the morbidity related to an unwarranted incision. In the hemodynamically unstable patient, several factors can influence the surgeon’s decision-making and lead to an inappropriate surgical strategy: • in patients with a ballistic thoracic wound, examination of the abdomen is neither sensitive nor specific. Abdominal guarding can wrongly lead to initial laparotomy; • the ballistic orifices can be misleading and are not predictive of the trajectory, in particular, when there is no exit orifice; • the thoracic drain output can be misleading. Output can be under-estimated when the drain is not correctly placed or when blood clots obstruct the chest tube. This may lead to the incorrect choice of initial laparotomy. Chest tube output can be high when intra-abdominal bleeding finds its way out through a destructive diaphragmatic injury and empties into the thorax. This may lead to the incorrect choice of first-line thoracotomy; • cardiac tamponnade can frequently be overlooked in ballistic trauma in spite of routine eFAST in the emergency room.
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Figure 11.
E. Hornez et al.
Algorithm for management of thoraco-abdominal wounds.
All in all, it is essential to know and follow the algorithm of TAI management (Fig. 11). Of note, even when the chest tube output is high (Fig. 11, arrow*), the initial approach is usually a laparotomy. Technically speaking, the abdominal approach should always be a midline laparotomy for abdominal trauma. For thoracic injuries, the surgical approach must be adapted to the suspected lesions. For a general surgeon, the clamshell thoracotomy often remains a solution that is simple and adaptable to most TAI. The treatment of lesions thereafter corresponds to the recommendations of damage control, organ by organ. Lastly, the following rules can be observed: • ‘‘diagnostic’’ opening of two cavities (thoracic and abdominal) is strongly inadvisable in the absence of formal indication because of increased morbidity; • an ‘‘exploratory’’ phrenotomy is also strongly inadvisable because of the mechanical ventilation disorders and associated morbidity this creates postoperatively; • when the damage control strategy is needed, it can be applied in both the abdomen and the thorax.
Inguino-crural wounds Inguinal wounds are defined as penetrating trauma in the groin, corresponding to all the soft tissues located in front of the hip joint and the femoral triangle. Lesions are largely dominated by femoral artery and vein injury, and secondarily by femoral nerve and hip joint injury. Clinical presentation is largely dominated by lower limb ischemia although massive bleeding is often reported [24].
Approach Draping should include the abdomen, the ipsilateral lower limb, and the contralateral thigh (for saphenous vein retrieval if necessary). The surgical approach should allow proximal and distal control of the common femoral artery. First-line extra-peritoneal control of the external iliac artery is unacceptable in this context because of its potential difficulty. A long midline laparotomy is recommended to
obtain control the common iliac artery at its origin [25]. A classical hockey-stick incision in the femoral triangle, medial to the Sartorius, can be extended as needed along the medical aspect of the thigh.
Treatment of lesions Simple clamping of the lesions is usually all that is needed for hemostasis. Venous hemostasis is often more difficult because the rich collateral circulation and the muscular mass volume in the area. In case of uncontrollable bleeding, wide ligation of the involved veins is advised. Once hemostasis is obtained, the principles of treatment are the same as for axillary wounds.
Conclusion Penetrating ballistic traumatisms are severe because of the initial hemorrhagic risk followed by the secondary risk of sepsis and finally because of the frequent sequelae of associated injury. Management within the context of massive afflux of victims is dictated by the hemodynamic status of the victim. Laparotomy, performed according to the specifications of damage control, allows first-line evaluation and control of bleeding lesions, thorough exploration of the gastro-intestinal tract from proximal to distal, with particular attention paid to segments on the borders of the intra-peritoneal space: esophago-gastric junction, duodenopancreatic block, extra-peritoneal rectum. Management of hemodynamically unstable pelvic wounds relies on surgery and EPP as well as instrumental methods such as REBOA and therapeutic angiography. For vascular injury, once bleeding has been arrested, temporary or definitive revascularization should be assured as soon as possible with a TVS. Arterial and/or venous ligation is the technique of choice to assure definitive hemostasis whenever revascularization is not possible. For ballistic wounds to contiguous compartments, therapeutic algorithms and surgical approaches are well codified. Treatment of lesions should
Management specificities for abdominal, pelvic and vascular penetrating trauma respect the principles of damage control aiming at rapid hemostasis. At the end, resort to specialized surgeons is often necessary, potentially after stabilization to allow transfer to an authorized trauma center. Essential points • Penetrating injury to the abdomen, pelvis, vessels and at the borderline between compartments are complex multiple injury situations with the initial risk related to bleeding and the secondary risk to sepsis. • Treatment of pelvic penetrating injuries is sequential: perineal examination, midline laparotomy, perineal treatment. • The therapeutic principles of rectal wounds are summarized by the four ‘‘D’’s: diversion (colostomy), debridement, drainage and distal lavage. • The surgical approach to vascular injuries should be large, allowing the surgeon to gain proximal and distal vascular control to stop the bleeding and assure temporary revascularization by insertion of a vascular shunt. • In the emergency setting, hemostasis of exteriorized bleeding of bi-compartmental bleeding is obtained by instrumental means: Foley catheter, tourniquets, junctional or hemostatic dressing compression. • In case of cervicothoracic injury, a midline sternotomy is recommended; extension can be cervical or subclavicular. • In case of axillary injury, the origin of the subclavian artery requires either a midline sternotomy for rightsided injury or third interspace anterior thoracotomy for left-sided injury.
Disclosure of interest The authors have not supplied their declaration of competing interest.
References [1] Owens BD, et al. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64: 295—9. [2] Montgomery SP, Swiecki CW, Shriver CD. The evaluation of casualties from Operation Iraqi Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 2005;201:7—12. [3] Behrman SW, Bertken KA, Stefanacci HA, Parks SN. Breakdown of intestinal repair after laparotomy for trauma: incidence, risk factors, and strategies for prevention. J Trauma 1998;45:227—33. [4] Seamon MJ, et al. A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma 2007;62:829—33.
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[5] Levy E, Cugnenc PH, Frileux P, et al. Postoperative peritonitis due to gastric and duodenal fistulas. Operative management by continuous intraluminal infusion and aspiration: report of 23 cases. Br J Surg 1984;71:543—6. [6] O’Donnel MT, Greer LT, Nelson J, Shriver C, Vertrees A. Diversion remains the standard of care for modern management of war-related rectal injuries. Mil Med 2014;179:778—82. [7] Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009;40:54—60. [8] Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015;79:523—32. [9] Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 2005;58:978—84. [10] Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma 1998;45:656—61. [11] Johnson EK, Judge T, Lundy J, Meyermann M. Diagnostic pelvic computed tomography in the rectal-injured combat casualty. Mil Med 2008;173:293—9. [12] Wu K, Posluszny Jr JA, Branch J, et al. Trauma to the pelvis: injuries to the rectum and genitourinary organs. Curr Trauma Rep 2015;1:8—15. [13] Percival TJ, Rasmussen TE. Reperfusion strategies in the management of extremity vascular injury with ischaemia. Br J Surg 2012;1:66—74. [14] Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006;61:8—12. [15] Hornez E, Boddaert G, Ngabou UD, et al. Temporary vascular shunt for damage control of extremity vascular injury: a toolbox for trauma surgeons. J Visc Surg 2015;152(6):363—8. [16] DeBakey ME, Simeone MC. Battle injuries of the arteries in World War Two: an analysis of 2471 cases. Ann Surg 1946;123:534—79. [17] Percival TJ, White JM, Ricci MA. Compartment syndrome in the setting of vascular injury. Perspect Vasc Surg Endovasc Ther 2011;23(2):119—24. [18] Van Waes OJ, Cheriex KCAL, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg 2012;99:149—54. [19] Lee T, Ducic Y, Gordin E, Stroman D. Management of carotid artery trauma. Craniomaxillofacial Trauma Reconstr 2014;7:175—89. [20] Demetriades D, Asensio JA. Subclavian and axillary vascular injuries. Surg Clin North Am 2001;81:1357—73. [21] Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association Critical Decisions in Trauma: penetrating neck trauma. J Trauma Acute Care Surg 2013;75:936—40. [22] Gill H, Jenkins W, Edu S, Bekker W, Nicol AJ, Navsaria PH. Civilian penetrating axillary artery injuries. World J Surg 2011;35:962—6. [23] Berg RJ, Inaba K, Okoye O, et al. The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 2014;77:684—91. [24] White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011;253:1184—9. [25] Lee JT, Bongard FS. Iliac vessel injuries. Surg Clin North Am 2002;82:21—48.
Available online at
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REVIEW
Management specificities for abdominal, pelvic and vascular penetrating trauma E. Hornez a,1, F. Béranger b,1, T. Monchal c,1, Y. Baudouin a, G. Boddaert d, H. De Lesquen b, S. Bourgouin c, Y. Goudard e, B. Malgras f, G. Pauleau e, V. Reslinger a, N. Mocellin a, C. Natale b, L. Meyrat b, J.-P. Avaro b,g, P. Balandraud c,g, S. Gaujoux h, S. Bonnet a,g,∗ a
Service de chirurgie viscérale et générale, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France b Service de chirurgie thoracique et vasculaire, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France c Service de chirurgie viscérale, hôpital d’instruction des armées Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France d Service de chirurgie thoracique et vasculaire, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France e Service de chirurgie digestive, endocrinienne et métabolique, HIA Laveran, 13013 Marseille, France f Service de chirurgie viscérale, hôpital d’instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France g École du Val-de-Grâce, 1, place Alphonse-Laveran, 75230 Paris cedex 05, France h Service de chirurgie digestive, hépatobiliaire et endocrinienne, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France Available online 26 November 2017
KEYWORDS Ballistic penetrating trauma; Damage control surgery
Summary Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient’s hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial
∗ Corresponding author at: Service de chirurgie viscérale et générale, hôpital d’instruction des armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart cedex, France. E-mail address: [email protected] (S. Bonnet). 1 These authors have contributed equally to this article.
https://doi.org/10.1016/j.jviscsurg.2017.10.009 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
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Packing; Vascular shunt; Multi-disciplinary approach; Hemostasis
E. Hornez et al. laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles. © 2017 Elsevier Masson SAS. All rights reserved.
Introduction Wartime wounds are typically penetrating injuries caused by bullets or flying debris. Abdominal wounds, generally of hollow organs, are most often multiple (4 to 5 per patient in recent combats) and represent between 10% and 20% of warfare wounds [1,2]. Truncal trauma, representing nearly half of preventable deaths, accounts for 20 to 30% of all deaths in warfare settings. Retroperitoneal organ involvement is more rare but severe. Ballistic injury to central great vessels (aorta, inferior vena cava and mesenteric vessels) is often associated with multiple and/or extensive other abdominal injuries. Pelvic wounds are severe, with mortality exceeding 30% when the rectum is involved [1]. Vascular injuries are prevalent and most concern limb injuries. Borderline compartment injuries are defined as penetrating trauma of frontier zones between two compartments (cervicothoracic, axillary, thoraco-abdominal and inguinal); they are characterized by frequent bleeding, anatomical complexity, difficulty in approach and surgical strategy. Complementary laboratory and imaging investigations are not very sensitive, and most often assessment of lesions is made during surgical exploration in the context of damage control. In the unstable patient, the goal of management is to obtain rapid hemostasis and hemodynamic stability to save the life of the wounded patient. If the patient is hemodynamically stable, the goal of management is first to correctly assess all injuries in order to perform the appropriate treatment urgently. The goal of this chapter is recall the specificities of the diagnostic and therapeutic management of patients sustaining penetrating trauma to the abdomen, pelvis, vessels and bordering compartments in the context of civilian warfare attacks and massive afflux of wounded.
Surgical approaches Laparotomy is a ‘‘crash-laparotomy’’, the incision is made with a cold blade scalpel. The patient is in shock; because of peripheral vaso-constriction, there is no worrisome bleeding during laparotomy and use of electrocautery is a loss of time. The laparotomy is on the midline.
Treatment of hemorrhage and contamination Rapid control of major bleeding In case of massive bleeding, the first gesture is manual compression of the abdominal aorta just below the diaphragm. The anesthesiologist can attest to the efficacy of the procedure when the arterial pressure rises. Manual compression can be replaced by supra-celiac cross clamping, after finger dissection of the muscular fibers of the crura. Simultaneously, the hemoperitoneum is rapidly evacuated with traditional and autologous blood recovery system suction. While in blunt trauma, pads are added in each quadrant to identify the origin of bleeding, the source of bleeding from ballistic wounds is much easier by the more localized nature of bleeding that can most often be controlled manually. A simple measure is to compress the mesenteric root between the thumb and index (Fig. 1). Once this compression is done, the two peritoneal sides can be incised and hemorrhage can be selectively controlled. If this is not possible, and in particular, when the superior mesentery artery is involved, hemorrhage control may require medial rotation of the viscera: • either from the right: Kocher maneuver followed by mesenteric disinsertion (Cattell and Braasch maneuver) (Fig. 2); • or from the left: left medial rotation of colon, spleen and pancreatic tail (Mattox maneuver) (Fig. 3).
Analytic treatment of hemorrhagic injuries
Abdominal wound specificities Hemodynamically unstable patient Principles Bleeding originating from solid organs is treated by resection (splenectomy, nephrectomy) or compression (peri-hepatic or retroperitoneal packing). Hollow organ injury is controlled by temporary measures: linear stapling. There is no place for stoma creation in the unstable patient. The main goal is only to stop peritoneal contamination.
Splenic injury should be treated by splenectomy according to the medial rotation technique. To control bleeding from the spleen rapidly, the spleen is pushed up on the spine and the posterior mesogastrium is opened until the spleno-pancreatic block is elevated into the midline, allowing approach to the splenic pedicle to control the bleeding. Liver hemorrhage is treated essentially by peri-hepatic packing (PHP). This procedure should be performed methodologically according to the instructions in the technical factsheet. If liver bleeding is intra-parenchymal, not rare when projectiles penetrate through the liver, ‘‘internal’’ packing can be achieved with a Penrose drain ligated at one extremity, or a Sengstaken—Blakemore tube, or even
Management specificities for abdominal, pelvic and vascular penetrating trauma
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Figure 1. Compression of the root of the mesentery between thumb and index fingers.
a finger of a surgical glove filled with saline (Fig. 4). Last, hemorrhage that persists in spite of initial packing requires revision of the original packing. If bleeding persists in spite of PHP that seems to be ‘‘well placed’’, arterial bleeding should be suspected and elective intra-fascial ligation of the hepatic artery should be entertained, taking care to place the ligation distal to the gastroduodenal artery take-off. Retroperitoneal hemorrhage or hematomas (RPH) can be central (aorta and vena cava), lateral (kidneys) or pelvic (pelvic fracture). Central RPH should be explored routinely. Before exploration, however, the supra-celiac aorta must be controlled. The retroperitoneum cannot be explored entirely by a single approach: either the Cattell and Braasch or the Mattox maneuver must be performed according to whether the surgeon needs to control the vena cava or the aorta, respectively. Lateral RPH requires exploration only if expanding or if the peritoneum has been violated but there is no active bleeding. Pelvic RPH requires extra-peritoneal packing.
Coprostasis or enterostasis This consists in closing gastro-intestinal defects with mechanical staplers, with no attempt to restore gastrointestinal continuity: this can be done at a later stage. If mechanical staplers are not available, the wounded intestinal segment can be tied off with vascular tapes or other means of ligation.
Hemodynamically stable or stabilized patient Principles In this setting, the lesions are usually mainly gastrointestinal, with little or no hemorrhage. However, the duration of operation should not exceed 60—90 minutes
Figure 2. Cattell and Braasch’s maneuver: right visceral rotation with extended duodenopancreatic mobilization followed by disinsertion of the mesenteric root.
to avoid the onset of post-traumatic coagulopathy, forerunner of the lethal triad (coagulopathy, acidosis and hypothermia). Here again, methodical exploration should precede repair(s). Exploration should proceed in the craniocaudal direction, starting with the abdominal esophagus and ending with the rectum. The pitfalls are areas that are not accessible without specific maneuvers: the esophagogastric junction, the posterior aspect of the stomach,
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Analytic treatment of lesions Duodenum Duodenal injuries occur in about 10% of warfare victims. Their severity is related to associated injuries and the chemical toxicity of duodenal secretions [3]. More than 50% involve the second portion of the duodenum. Their diagnosis is not always obvious and treatment after delayed diagnosis can be most difficult. The 3 B rule merits to be known: Bile leakage, presence of air-filled Blebs, and Blood in the form of peri-duodenal hematoma. The presence of even one ‘‘B’’ calls for compete exploration of the duodenum, requiring a Kocher maneuver. The choice of treatment should take into consideration the size of the wound (in relation to the circumference of the duodenal lumen), the location (in relation to he papilla) and associated lesions. Treatment consists of simple duodenorrhaphy, duodeno-jejunostomy or drainage.
Duodenorraphy Simple duodenorraphy is possible if the resultant stenosis of the duodenal lumen is less than 50%.
Duodeno-jejunostomy
Figure 3. Mattox’ maneuver: left visceral rotation with mesogastric dissection and medialization of the spleen and pancreas.
Figure 4. saline.
‘‘Internal packing’’ with a glove finger filled with
the duodeno-jejunal junction, the mesenteric border of the small intestines, the mesocolic border of the transverse colon and the affixed aspects of the colon. Repair techniques should be adapted to the injured organ. The stomach and the small intestines are not at all problematic, since most are amenable to debridement-suture closure or resection-anastomosis, realizing that the only limitation is the remnant length. The gastro-intestinal segments that pose the most difficult problems are the duodenum and the colon. The surgical approaches are not any different from those used for the unstable patient.
When the wound involves more than 50% of the duodenal circumference, and in particular when the second portion is involved, there are several options, including side-to-end Roux-en Y duodeno-jejunostomy, jejunal patch or duodenal derivation. These techniques are reserved for destructive wounds, especially combined duodenal and pancreatic lesions where the probability of suture repair failure is high. The common point is that they divert the alimentary flow from the repair. Such diversions can consist of simple pyloric exclusion associated with gastro-jejunostomy or a tube duodenostomy. Pyloric exclusion is simple to perform, and the diversion is reversible. The pylorus is closed either by endolumenal sutures inserted through a gastrotomy, or extra-lumenal mechanical suture without division. Whatever the technique, exclusion is completed by a gastro-jejunostomy. The pylorus opens up spontaneously within two to three weeks in 90% of patients. The main disadvantage is the possibility of marginal peptic ulcer at the level of the gastro-jejunostomy. The second disadvantage is that some duodenal fistulas can occur after three weeks [3], when the pylorus might be patent. Tube ‘‘duodenostomy’’ consists in duodenal repair and placement of two jejunostomies and one gastrostomy: • the first jejunostomy is retrograde, and ‘‘decompresses’’ the repair; • the second jejunostomy is downstream, and is used for feeding; • the third tube is a gastrostomy placed upstream from repair, the goal of which is to divert the gastric juices. This tube can be placed through the pylorus and then becomes a gastro-duodenostomy.
Drainage The use of diverting techniques has recently been called into question [4]. Another option, particularly when the wound is heavily damaged or seen at a late stage, could be to insert a Levy ‘‘spiral’’ drain after debridement of the wound edges [5]. This device is comprised of a suction system coupled with an irrigation system, destined to neutralize the duodenal content that always seems to seep around the drain.
Pancreas Just as for duodenal wounds, a suspected pancreatic wound calls for careful exploration also requiring a Kocher
Management specificities for abdominal, pelvic and vascular penetrating trauma maneuver combined with division of the gastro-colic ligament. Wide drainage is essential, using irrigation-drainage modules. The only indications for resection are when the main pancreatic duct is wounded to the left of the isthmus, which should be treated by distal pancreatectomy. Transection of the main duct to the right of the isthmus should be drained; duodeno-pancreatectomy is proscribed in this context.
Colon Left colon The dogma is to divert all ballistic wounds of the left colon [6]. In practical terms, ‘‘colonic diversion’’, in the broadest sense of the term, can consist of: • exteriorization of a small wound, easily brought out through the abdominal wall (typically small wounds of the sigmoid or transverse colons); • suture repair ‘‘protected’’ by an upstream colostomy, if the wound is located in a fixed segment (hepatic or splenic flexure, rectum); • extended resection without anastomosis. The distal stump is closed and left in the abdomen while the proximal segment is brought out through the abdominal wall (a typical Hartmann procedure for extended wounds of the sigmoid colon).
Right colon Right colonic wounds can be treated by simple suture repair or resection-anastomosis, but once again, if there is any doubt as to a difficult postoperative course (exsanguinated patient, multiple lesions), a diversion should be envisioned (ileostomy rather than cecostomy).
Transverse colon Transverse colonic wounds are often considered as rightsided wounds, however with a ‘‘better’’ prognosis, that are potentially amenable to single stage treatment. In fact, these are usually severe lesions, not in themselves, but because of the frequent association with lesions of the pancreas, spleen, or stomach due to the central location of the ballistic wound. The high rate of anastomotic fistula after primary repair makes this approach prohibitive in certain series (around 25%) meaning that good judgment should guide the surgeon’s attitude more than dogma.
Specificities for management of pelvic wounds Initial management Pelvic wounds are defined by lesions that extend beyond the bony framework and can involve pelvic contents, vessels, intestinal or urinary tract. The initial step is to examine the patient supine and completely undressed. The surgeon looks for wounds and contusions, making sure to examine the back, the buttocks and the perineum. Ballistic impacts and orifices are examined for leakage of blood, feces or urine. Digital investigation is important to evaluate the position of the prostate and the tonicity of the sphincters (in the conscious patient). In this context, blood in the rectal ampulla is considered evidence of a colonic wound until proven otherwise. Blood in the urine (hematuria or uretrorrhagia) attests to injury of the urinary tract. Insertion of a bladder catheter is contraindicated in the presence of uretrorrhagia or suspicion of urethral injury. The examiner must check for femoral pulse
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and potential vascular, nervous, bony injuries (palpation of the pelvis) or a hip joint problem. A pelvic X-ray may indicate bone fracture or the presence of a projectile. Extended Focused Assessment with Sonography for Trauma (eFAST) is performed in the emergency bay to search for abdominal fluid. If the patient is hemodynamically stable, a total body CT scan is performed to complete the initial workup and this investigation has a good sensitivity and specificity to analyze the missile trajectory.
Hemodynamically unstable patient Management of in-extremis patients, who are initially nonstabilized with refractory hemorrhagic shock, imposes the need for rapid decisions and aggressive damage control maneuvers, as described. In patients who are unstable despite initial resuscitative measures, hemostatic maneuvers depend on the results of the eFAST investigation.
Negative eFAST If the eFAST is negative, the bleeding is from the pelvis alone and, in this case, the therapeutic possibilities are extraperitoneal packing (EPP) performed a soon as possible in the emergency bay [7] to effectively control venous bleeding, and, according to local expertise, insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) [8] to stabilize the patient until arterial embolization or arterial covered stent insertion can be performed.
Extra-peritoneal packing (EPP) EPP is performed in the supine patient under general anesthesia. An 8 cm suprapubic midline incision is performed, the linea alba is opened. The peritoneum is displaced cephalad, taking care not to open it. This is of capital importance because an intact peritoneum is necessary to assure most of the counter-pressure of the packing. This maneuver allows access to the anterior aspect of the bladder and the subperitoneal hematoma, which is usually under some pressure. Blood clots are removed digitally, and laparotomy pads are inserted one after the other into the lateral rectal spaces of Retzius and Bogros. Improvement of arterial pressure should be immediate with an increase of 20 to 30 mmHg. Afterwards, only the skin is closed with staples and a pelvic compressive wrap is placed and tightened to reduce the pelvic volume as much as possible.
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Intra-aortic balloon occlusion is an alternative to surgical cross clamping of the aorta and allows control of infra-diaphragmatic arterial bleeding while favoring redistribution of circulating blood volume to the heart and brain. The REBOA is inserted via a surgical approach to the common femoral artery that is punctured under direct vision. The balloon should be inflated below the renal arteries. An improvement in blood pressure should be immediate.
Arteriography Therapeutic arteriography is part of radiologic damage control. It allows selective embolization of injured arteries while respecting the surrounding tissues and the pressure within the retroperitoneal hematoma, which favors spontaneous hemostasis. In patients with catastrophic bleeding, it may be necessary to perform more proximal embolization, at the level of the internal iliac artery [9]. For hemorrhage originating from the common or external iliac artery, insertion of a coated stent may be envisioned.
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Positive eFAST If eFAST is positive, abdomino-pelvic damage control should be performed (only the specificities of the pelvic component are dealt with in this paragraph) starting with a xipho-pubic midline laparotomy. The pelvis is packed, which often allows temporary hemostasis. The pads are then removed to determine the lesions. Management then depends on the origin of the bleeding: • arterial bleeding coming from the mesorectum or the bladder is an indication for directed hemostasis by Vicryl 2.0 suture ligatures; • for arterial bleeding, proximal control is obtained at the level of the infrarenal aorta or common iliac while distal control is obtained at the level of the external iliac artery. If arterial bleeding is coming from the internal iliac, proximal ligation is indicated, sometimes bilaterally. In case if injury to the common or external iliac artery, the vessel should be suture repaired, if possible; if not, a temporary vascular shunt should be inserted. Simple ligation at this level leads to lower limb ischemia in 50% of patients and therefore a femoro-femoral cross-over bypass should be performed; • in case of venous hemorrhage, temporary control can be obtained by direct compression with swabs on-a-stick. In case of injury to the common or external iliac vein, simple suture repair can be performed if possible; if not ligation is the rule. When the origin of bleeding is deep, intraperitoneal pelvic packing is performed by insertion of pads into the latero-rectal fossa and behind the bladder. The pressure of the packing should be sufficient to compress the venous structures against the bone.
Hemodynamically stable or stabilized patient Rectal injury Surgical management proceeds in three steps: initial perineal examination under general anesthesia; second, abdominal diagnosis via an exploratory laparotomy which allows treatment of lesions and routine colostomy; and third, perineal therapy to treat the perineal injuries and drain the cellular spaces. Management can be summarized by the 4 D’s: drainage, diversion, distal wash-out and damage repair.
First step: perineal examination under general anesthesia Anoscopy should be performed with precaution: submucosal hematoma attests indirectly to sphincteric injury. Direct repair should be envisioned whenever possible, either transanally for distal lesions, or through the wound itself, for destructive penetrating trauma by projectile.
Figure 5. space.
Drainage of both ischio-rectal fossa and the presacral
• the rectal wound is destructive: a Hartmann resection is necessary. The operative strategy can be simplified whenever necessary by simple staple closure of the sigmoid, without any stoma, to exclude the rectum and decrease distal contamination. The staple line should be at the level of the sigmoid loop and will become the distal stump for later reconstruction. Last three steps: debridement, drainage, distal lavage. The last and third step, performed through a perineal approach, includes wide debridement of the missile tracts and orifices with counter incisions. The ischio-rectal fossae are drained routinely (Fig. 5) [10]. The para-rectal spaces are opened lateral to the rectum, at 3 and 6 o’clock, between the palpable external sphincter and the ischium. The subcutaneous tissues are then opened with scissors or by finger dissection until reaching the ischio-rectal fossa. Lateral drainage should be extended until reaching the levators, felt by palpation. If the trajectory leads to suspicion of a sub-peritoneal rectal wound, or whenever a doubt persists as to this, the levator muscle can be divided to insert a Delbet type drain (corrugated sheet drain) in contact with the rectal wall. Drainage of the presacral space is not routine [11], but is necessary when the posterior aspect of the rectum is involved. This requires opening the presacral space by dividing the anococcygeal raphe. It is recommended to copiously lavage the space with a betadine solution before inserting the Delbet drains. Anal sphincter injuries should always be repaired as soon as possible, since secondary identification of the sphincter edges is often very difficult. Dissection should be limited in order to allow tension-free end-to-end suture repair whenever possible.
Second step: midline xipho-pubic laparotomy, colostomy
Urinary tract injury
Two scenarios are possible [6]: • the rectal wound is not destructive, often only subperitoneal, as suggested by the trajectory and the information gleaned from the initial perineal examination. The presence of hematoma or air bubbles under the peritoneum should lead to digital exploration through the hematoma or incision of the peritoneum to access the mesorectal planes. A rectal lesion can be either simply drained or repaired if possible. A terminalized lateral colostomy just proximal to the lesion should be the rule;
Bladder injuries require a wide, vertical cystotomy, allowing full inspection of the bladder wall and visualization of the ureteral orifices. Devitalized tissues are debrided, followed by watertight closure, with a single layer of Vicryl 0 that should not include the pre-vesical fatty tissues. The bladder is drained by a trans-urethral or suprapubic catheter [12]. If there is ureteral injury, immediate repair, which may be time-consuming, is not recommended. In case of partial ureteral rupture (less than 50% of the circumference), an 8 French catheter is inserted and secured to the ureter by a
Management specificities for abdominal, pelvic and vascular penetrating trauma Vicryl 2.0 tie, then exteriorized through the skin. In case of complete ureteral disruption, the ureter is ligated with nonabsorbable suture material and a percutaneous nephrostomy is performed.
Perineal vaginal or scrotal wounds Positive diagnosis is made by inspection of the perineum. During the first step of lesion workup, these wounds are simply debrided and dressed. Scrotal closure enhances testicular preservation.
Soft tissue and pelvic injuries Soft tissues are debrided at the level of the entry and exit orifices, as well as along the trajectory of the projectile. Devitalized tissues are excised and foreign bodies are removed. In case of bone injury, all bony splinters are removed. These wounds are often destructive. Repeated debridement may be necessary to evaluate the evolution of tissue viability, which can change over time. Wound care may be facilitated by negative pressure dressings. For penetrating trauma, bony injuries are usually nondisplaced or minimally so, and fractures are rarely unstable. When bony injuries are unstable, they require an external fixator or a pelvic clamp. For fractures of the proximal extremity of the femur or the acetabulum, trans-condylar traction is placed while awaiting definitive treatment.
Specificities of vascular injuries Clinical diagnosis and evaluation Clinical examination must be systematic, simple, rapid and efficient. It should be bilateral and comparative, searching for major and minor signs of arterial involvement. Major signs are active exteriorized hemorrhage, pulsatile hematoma, absence of distal pulses and signs of frank ischemia (6 ‘‘P’’’s ‘‘pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis’’). In these clinical situations, nothing should delay surgical management in the operating room. Diagnosis can sometimes be more difficult when signs of arterial involvement are less obvious, i.e., when minor signs are found such as asymmetrical pulses, diminished pulse, penetrating wound near a vascular structure, hematoma, or patient in shock. If the victim is stable, complementary investigations can then be performed: these include Doppler sonography to measure the intensity of arterial flow and detect a potential diminution of the arterial pressure index; an angio-CT scan can locate the vascular injury and detect lesions such as false aneurysms, ruptures, dissections and intramural hematoma; intraoperative ontable arteriography may be necessary to identify the lesions and control their repair.
Initial management Whenever possible in the management of severely bleeding victims, at least two operators enhances satisfactory progress of the operation and helps decrease the duration (ideally < 60 min). Three steps are essential: • control of exteriorized bleeding: placing a tourniquet just proximal to the injury or at the proximal end of the thigh or arm is effective in stopping the hemorrhage. If this is not possible (junctional areas where a tourniquet
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cannot be placed), the operative assistant must apply direct pressure on or just proximal to the arterial lesion. It is also possible to inflate a Foley catheter balloon inserted directly into the vascular wound; • reduction of long bone fracture allows, in certain cases, to decrease the bleeding and above all to restore distal flow; • rapid transfer to the operating room.
Surgical management Equipment must be adapted and specific for the vascular repair (microsurgery, atraumatic clamps). The patient should be perfectly positioned as in elective surgery using the same landmarks. Clamps should be wide-jawed and be adapted to use in the contralateral limb or the upper limb to gain access for a venous graft if necessary. The surgical approach should be large enough to permit optimal proximal and distal vascular control of other associated vessels.
Proximal and distal control To control bleeding, it is mandatory to access the vessel proximal to the injury. For proximal lower limb injury, the inguinal ligament may need to be divided while the assistant applies direct compression on the injury. A trans-iliac, transor retroperitoneal access to the common and/or external iliac artery is very effective to control these hemorrhages. For the brachial artery, proximal control is obtained in the delto-pectoral groove splitting the muscular fibers of the pectoralis major and dividing the pectoralis minor muscle while taking care to avoid injury to any nerve fibers of the brachial plexus. Lastly, control of the subclavian arteries is obtained via a sternotomy on the right, and antero-lateral 4th interspace thoracotomy on the left.
Arterial debridement Adequate arterial debridement is necessary to obtain healthy tissues for arterial repair. Effectively there is a risk of early loss of patency if repair is performed in injured areas (intimal dissection, sub-intimal hematoma).
Proximal and distal thrombectomy After obtaining proximal and distal control and after debridement of the arterial edges, a Fogarty catheter is introduced routinely up and downstream to evacuate any potential thrombi (more often found distally).
Purging/rinsing of up and downstream arterial segments Cautious declamping, first upstream, then downstream purges the vessel. The lumen is then rinsed proximally and distally with heparin solution (12,500 to 25,000 UI/L).
Revascularization When a hospital is faced with a massive afflux of trauma victims, the duration of operation must be reduced to a minimum. Once the hemorrhage is controlled, the operators mush ensure definitive or temporary revascularization as possible. Only simple non-time-consuming vascular repairs should be undertaken. The reference technique, reversed saphenous vein bypass, [13] is not indicated in the damage control setting but will be performed later (24 h to 72 h) during the definitive vascular repair session. The suture
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E. Hornez et al. truncal and terminal arteries (Fig. 7) [16]. From the technical viewpoint particular to warfare surgery, arteries should be ligated at a distance from the trauma zone to avoid blowout of the stump in case of local infection.
Venous injuries
Figure 6.
®
Example of (Javid ) temporary vascular shunt.
material used must be adapted to the caliber of the vessel ® (double armed Prolene 5.0, 6.0 and 7.0 for the smallest vessel caliber). The type of repair depends on the degree of injury.
Whenever possible, particularly for large caliber veins such as the common femoral or iliac veins, direct venous repair or saphenous graft should be entertained to limit postoperative complications such as venous hypertension with edema. If complete (bypass) venous repair is envisioned, the artery too must be repaired to limit the duration of ischemia. If not, it is usual practice to treat the venous injury before the arterial injury, because treatment is most often simple (ligation), takes little time and favors arterial repair. Nonetheless, proximal and distal control can be intricate due to the existence of numerous venous collaterals and difficulty of dissection of these more fragile vessels. Occasionally it is useful to temporarily clamp the arterial inflow to decrease the venous return, facilitating venous hemostasis.
Direct lateral repair
Protection of vascular repair
This is adequate for small puncture wounds; caution must be exercised to avoid creating any stenosis.
Protection of vascular repairs is essential to limit the risk of sepsis and early anastomotic breakdown that can be lethal for the patient. This can be achieved by musculo-cutaneous flaps or more simply by negative pressure therapy with a specific interface to protect the vessels. When musculocutaneous destruction is massive and it is impossible to provide coverage, the bypass can be tunneled, as far as possible from the lesion, to limit sepsis involving the vascular repair.
Resection followed by end-to-end anastomosis This technique is used for transections with less than 2 cm loss of substance and is generally easily performed in young victims with healthy arteries after sufficient arterial debridement and mobilization. Nonetheless, a tension-free repair must be to ensure perfect postoperative patency. If the loss of substance is greater than 2 cm, temporary revascularization can be ensured by insertion of a temporary vascular shunt or a prosthetic repair with poly-tetra-fluoroethylene (PTFE) or Dacron graft.
Use of temporary vascular shunts (TVS) In the literature, this type of apparatus is used for rapid revascularization of extremities before definitive surgery in the following situations [14,15]: • saturation of health care facility by afflux of wounded; • severe patient status with hemorrhagic shock in the framework of surgical damage control; • open compound fracture requiring primary bone fixation. TVS is a reliable, easy and quick way to restore limb vascularization and patency can persist for up to 72 hours. The principle is to bypass the injured area by a supple, tubular structure between the downstream and upstream arterial (or venous) segments. There are several specific vascular shunts available on the market (Fig. 6), but, in the emergency setting, a tracheal suction tube, a Redon type drain, or any sort of drain adapted to the size of the vessel can suffice and assure temporary vascularization. Its placement is relatively easy, requiring local upstream and downstream heparinization, but, above all, it requires secure fixation to avoid untimely removal. If temporary revascularization is not possible (substantial loss of substance, shunt not available), definitive hemostasis should be obtained by arterial or venous ligation.
Arterial ligation Arterial ligation sacrificing the territorial vascularization of a portion of a limb is part of vascular damage control when hemorrhagic lesions are life-threatening. Debakey and Simeone published a list of arteries that can be ligated without major ischemia, making a differentiation between
Fasciotomies Definitive or temporary revascularization is usually never done immediately but rather four to six hours after the trauma. Because of this, it is imperative to prevent the onset of a compartment syndrome by performing routine fasciotomies (in the forearm essentially for the upper limb, and in the leg for the lower limb) (Fig. 8). These fasciotomies must be performed correctly and prophylactically at the very beginning of management [17].
Postoperative surveillance Initial surveillance is clinical, to assure that bleeding has completely stopped and that vascular repair is effective (peripheral pulses present). If this is not the case, the vascular repair has to be visualized by arteriography or angio-CT scan, or by repeat surgery.
Specificities in management of lower and upper anatomic borders of the trunk Adjacent compartment wounds (cervicothoracic, axillary, thoraco-abdominal and inguinal) present common features: hemorrhagic characteristic, anatomic complexity and difficulties in the surgical approach and strategy.
Cervicothoracic wounds Management in the emergency room Rapid examination of the patient is necessary to evaluate the usefulness of direct hemostasis. This can be
Management specificities for abdominal, pelvic and vascular penetrating trauma
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Figure 7. List of arteries that can be ligated without major ischemic consequences. From DeBakey and Simeone, representing the percentage of amputation according to the vascular territory ligated.
obtained by a compressive dressing, or a large (at least 22 gauge) Foley catheter introduced through the wound and then maximally inflated and placed on continuous traction (Fig. 9) [18].
Management in the operating room Approach The neck, thorax and abdomen have to be prepped and draped. The surgical approach needs to be simple, wide and extended as needed. Initial sternotomy is clearly recommended because it allows access to the entire aortic arch. If cardiac arrest occurs, the initial approach should be an anterior clamshell bi-thoracotomy that allows first-line internal cardiac massage and clamping of the descending aorta. The incision can be extended by sternotomy for further hemostasis. Once the sternotomy has been performed, access to the aortic arch for temporary arterial hemostasis can be achieved by routine division of the left innominate vein. Venous injuries are initially controlled by packs or sponges on-a-stick. In case proximal control is necessary for one of the great vessels, a cervical or subclavicular extension can be made (with transection of the clavicle if necessary). The pleura should be opened routinely in order not to miss intrathoracic bleeding from the subclavian vessels.
Treatment Vascular injuries Arterial injuries include the common carotid, the subclavian and vertebral arteries. Carotid artery injuries warrant routine revascularization because of the poor prognosis associated with simple ligation [19]. There are however several situations that contraindicate revascularization, as summarized in Table 1. In some specific cases, temporary vascular shunts are recommended [15]. Common carotid reimplantations should be on the subclavian artery rather than the aortic arch. Emergency revascularization of the subclavian artery is not recommended [20]. The peri-scapular arterial anastomotic network is rich and acute ischemia occurs rarely. However, in the hemodynamically stable patient presenting with a bleeding subclavian artery injury distal to the take-off of the vertebral artery, revascularization is indicated, ideally by insertion of a TVS. Vertebral artery injury calls for simple ligation. For venous injury, the constraints are not as important. Most of the veins in this region can be ligated without the need of revascularization. Only bilateral internal jugular ligation is contra-indicated. Insertion of a large TVS is a satisfactory alternative to ligation.
Respiratory apparatus injury In case of tracheal destruction (rare in patients who survive), the tracheal intubation tube should be pushed beyond the
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Figure 8. Fasciotomy incisions for the upper and lower extremities: a: upper extremity: two incisions on the anterior and posterior surfaces of the forearm; b: lower extremity: opening of all four compartments through a single cutaneous incision on the lateral aspect of the lower leg.
Esophageal injury Ballistic wounds of the esophagus should be closed primarily [21] with full-thickness slowly absorbable or non-absorbable 3.0 sutures. Routine mediastinal drainage and nasogastric tube are indicated. A muscular flap (sterno-cleido-mastoid or intercostal) to cover the suture line is recommended in case of associated vascular injury. In case of loss of substance contra-indicating primary suture of the esophagus, closure over a large caliber T-tube is recommended. The extremity of the drain is exteriorized through a cervical contra-incision. Destructive wounds of the esophagus require exclusion by stapling the distal segment and left lateral cervical esophagostomy [21]. Mediastinal drainage is routine.
Axillary wounds Ballistic wounds in the axillary region include associated arterial, venous and brachial plexus injuries in one third of victims. In the larger series in the literature, fewer than 20% bleed and are hemodynamically unstable at initial management; fewer than 15% present acute upper limb ischemia [22]. Figure 9. Temporary hemostasis of a cervicothoracic wound. A large-bore Foley catheter is introduced directly through the wound orifice, inflated maximally, and then placed on traction. This results in compression of the vascular elements against the surrounding bony structures.
injury and inflated to ensure air-tightness. Wounds of the pulmonary apex require simple stapling or tractotomy, which assures hemostasis and aerostasis simultaneously. Thoracic drainage should be routine.
Surgical approach Draping should include the ipsilateral hemithorax, the entire upper limb and the thigh for eventual saphenous vein graft retrieval. The approach should allow proximal and distal control of the axillary artery. In the presence of expanding hematoma in the subclavicular and/or axillary hollow, it control the subclavian artery at its origin is strongly recommended before approaching the axillary artery. This control is obtained, on the right, by a midline sternotomy, and on the left by a 4th intercostal left anterior thoracotomy. The
Management specificities for abdominal, pelvic and vascular penetrating trauma Table 1
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Management of cervicothoracic vascular injuries in the context of damage control surgery. Action
Exceptions
Common carotid artery
Routine revascularization
Subclavian artery
Ligation
Ligation if: refractive SAP < 70 mmHg; areactive bilateral mydriasis; associated cranio-encephalic injury; associated destructive neck injury; absence of back flow Revascularization if: injury distal to the run-off of the vertebral artery in a stable patient
Vertebral artery Great mediastinal vein
Ligation Ligation
Revascularization if: bilateral internal jugular vein injury
SAP: systolic arterial pressure.
axillary artery is approached directly through the deltopectoral groove eventually extended along the arm medially. This requires routine division of the pectoralis minor insertion and incision of the pectoralis fascia. The insertion of the pectoralis major can be divided if necessary.
Treatment of lesions Once hemostasis has been accomplished by clamps, specialized vascular surgeons should be solicited (if management is in a trauma center). In their absence and if transfer of the patient is necessary, the general surgeon must adhere to damage Control principles as follows: • axillary artery wounds should be revascularized with a TVS; • venous injuries should be either ligated or shunted with a TVS; • brachial plexus wounds require simple landmarking of nerve roots (non-absorbable 3.0 monofilament) or therapeutic abstention; • soft tissue hemorrhage should be treated by packing, potentially with hemostatic compresses (e.g., ® QuickClot ).
Thoraco-abdominale injuries Thoraco-abdominal injuries (TAI) are defined by concomitant abdominal and thoracic compartment lesions associated with some degree of diaphragmatic injury. Such lesions are strongly suspected clinically when the entry orifice is located between the fourth costal interspace (nipple line in men) and the costal margin. Management of ballistic TAI requires a systematic approach because of its severity. Reported mortality ranges between 30 and 40% [23]. Management is resolutely surgical and non-operative treatment is exceptional. The surgical approach includes a laparotomy in more than 80% of cases, associated with thoracotomy in 15 to 30% of cases. When it is necessary to open both compartments, the reported mortality increases to 60% [23].
Emergency management Hemodynamically unstable patients should be managed immediately in the emergency room similarly to those with cervicothoracic wounds. It is however illusory to try to assure instrumental hemostasis. Bubbling or sucking wounds should be sealed by a dressing overlapping at least three ribs (Fig. 10) or an Asherman valve. Chest tube drainage should
Figure 10. Three-rib compressive dressing to occlude a sucking chest gunshot wound.
be routine in the presence of X-ray detected hemothorax or pneumothorax.
Operative room management The main difficulty here is to correctly choose the first compartment to open in order to obtain rapid hemostasis, while limiting the morbidity related to an unwarranted incision. In the hemodynamically unstable patient, several factors can influence the surgeon’s decision-making and lead to an inappropriate surgical strategy: • in patients with a ballistic thoracic wound, examination of the abdomen is neither sensitive nor specific. Abdominal guarding can wrongly lead to initial laparotomy; • the ballistic orifices can be misleading and are not predictive of the trajectory, in particular, when there is no exit orifice; • the thoracic drain output can be misleading. Output can be under-estimated when the drain is not correctly placed or when blood clots obstruct the chest tube. This may lead to the incorrect choice of initial laparotomy. Chest tube output can be high when intra-abdominal bleeding finds its way out through a destructive diaphragmatic injury and empties into the thorax. This may lead to the incorrect choice of first-line thoracotomy; • cardiac tamponnade can frequently be overlooked in ballistic trauma in spite of routine eFAST in the emergency room.
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Figure 11.
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Algorithm for management of thoraco-abdominal wounds.
All in all, it is essential to know and follow the algorithm of TAI management (Fig. 11). Of note, even when the chest tube output is high (Fig. 11, arrow*), the initial approach is usually a laparotomy. Technically speaking, the abdominal approach should always be a midline laparotomy for abdominal trauma. For thoracic injuries, the surgical approach must be adapted to the suspected lesions. For a general surgeon, the clamshell thoracotomy often remains a solution that is simple and adaptable to most TAI. The treatment of lesions thereafter corresponds to the recommendations of damage control, organ by organ. Lastly, the following rules can be observed: • ‘‘diagnostic’’ opening of two cavities (thoracic and abdominal) is strongly inadvisable in the absence of formal indication because of increased morbidity; • an ‘‘exploratory’’ phrenotomy is also strongly inadvisable because of the mechanical ventilation disorders and associated morbidity this creates postoperatively; • when the damage control strategy is needed, it can be applied in both the abdomen and the thorax.
Inguino-crural wounds Inguinal wounds are defined as penetrating trauma in the groin, corresponding to all the soft tissues located in front of the hip joint and the femoral triangle. Lesions are largely dominated by femoral artery and vein injury, and secondarily by femoral nerve and hip joint injury. Clinical presentation is largely dominated by lower limb ischemia although massive bleeding is often reported [24].
Approach Draping should include the abdomen, the ipsilateral lower limb, and the contralateral thigh (for saphenous vein retrieval if necessary). The surgical approach should allow proximal and distal control of the common femoral artery. First-line extra-peritoneal control of the external iliac artery is unacceptable in this context because of its potential difficulty. A long midline laparotomy is recommended to
obtain control the common iliac artery at its origin [25]. A classical hockey-stick incision in the femoral triangle, medial to the Sartorius, can be extended as needed along the medical aspect of the thigh.
Treatment of lesions Simple clamping of the lesions is usually all that is needed for hemostasis. Venous hemostasis is often more difficult because the rich collateral circulation and the muscular mass volume in the area. In case of uncontrollable bleeding, wide ligation of the involved veins is advised. Once hemostasis is obtained, the principles of treatment are the same as for axillary wounds.
Conclusion Penetrating ballistic traumatisms are severe because of the initial hemorrhagic risk followed by the secondary risk of sepsis and finally because of the frequent sequelae of associated injury. Management within the context of massive afflux of victims is dictated by the hemodynamic status of the victim. Laparotomy, performed according to the specifications of damage control, allows first-line evaluation and control of bleeding lesions, thorough exploration of the gastro-intestinal tract from proximal to distal, with particular attention paid to segments on the borders of the intra-peritoneal space: esophago-gastric junction, duodenopancreatic block, extra-peritoneal rectum. Management of hemodynamically unstable pelvic wounds relies on surgery and EPP as well as instrumental methods such as REBOA and therapeutic angiography. For vascular injury, once bleeding has been arrested, temporary or definitive revascularization should be assured as soon as possible with a TVS. Arterial and/or venous ligation is the technique of choice to assure definitive hemostasis whenever revascularization is not possible. For ballistic wounds to contiguous compartments, therapeutic algorithms and surgical approaches are well codified. Treatment of lesions should
Management specificities for abdominal, pelvic and vascular penetrating trauma respect the principles of damage control aiming at rapid hemostasis. At the end, resort to specialized surgeons is often necessary, potentially after stabilization to allow transfer to an authorized trauma center. Essential points • Penetrating injury to the abdomen, pelvis, vessels and at the borderline between compartments are complex multiple injury situations with the initial risk related to bleeding and the secondary risk to sepsis. • Treatment of pelvic penetrating injuries is sequential: perineal examination, midline laparotomy, perineal treatment. • The therapeutic principles of rectal wounds are summarized by the four ‘‘D’’s: diversion (colostomy), debridement, drainage and distal lavage. • The surgical approach to vascular injuries should be large, allowing the surgeon to gain proximal and distal vascular control to stop the bleeding and assure temporary revascularization by insertion of a vascular shunt. • In the emergency setting, hemostasis of exteriorized bleeding of bi-compartmental bleeding is obtained by instrumental means: Foley catheter, tourniquets, junctional or hemostatic dressing compression. • In case of cervicothoracic injury, a midline sternotomy is recommended; extension can be cervical or subclavicular. • In case of axillary injury, the origin of the subclavian artery requires either a midline sternotomy for rightsided injury or third interspace anterior thoracotomy for left-sided injury.
Disclosure of interest The authors have not supplied their declaration of competing interest.
References [1] Owens BD, et al. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008;64: 295—9. [2] Montgomery SP, Swiecki CW, Shriver CD. The evaluation of casualties from Operation Iraqi Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 2005;201:7—12. [3] Behrman SW, Bertken KA, Stefanacci HA, Parks SN. Breakdown of intestinal repair after laparotomy for trauma: incidence, risk factors, and strategies for prevention. J Trauma 1998;45:227—33. [4] Seamon MJ, et al. A ten-year retrospective review: does pyloric exclusion improve clinical outcome after penetrating duodenal and combined pancreaticoduodenal injuries? J Trauma 2007;62:829—33.
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[5] Levy E, Cugnenc PH, Frileux P, et al. Postoperative peritonitis due to gastric and duodenal fistulas. Operative management by continuous intraluminal infusion and aspiration: report of 23 cases. Br J Surg 1984;71:543—6. [6] O’Donnel MT, Greer LT, Nelson J, Shriver C, Vertrees A. Diversion remains the standard of care for modern management of war-related rectal injuries. Mil Med 2014;179:778—82. [7] Osborn PM, Smith WR, Moore EE, et al. Direct retroperitoneal pelvic packing versus pelvic angiography: a comparison of two management protocols for haemodynamically unstable pelvic fractures. Injury 2009;40:54—60. [8] Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015;79:523—32. [9] Fangio P, Asehnoune K, Edouard A, Smail N, Benhamou D. Early embolization and vasopressor administration for management of life-threatening hemorrhage from pelvic fracture. J Trauma 2005;58:978—84. [10] Gonzalez RP, Falimirski ME, Holevar MR. The role of presacral drainage in the management of penetrating rectal injuries. J Trauma 1998;45:656—61. [11] Johnson EK, Judge T, Lundy J, Meyermann M. Diagnostic pelvic computed tomography in the rectal-injured combat casualty. Mil Med 2008;173:293—9. [12] Wu K, Posluszny Jr JA, Branch J, et al. Trauma to the pelvis: injuries to the rectum and genitourinary organs. Curr Trauma Rep 2015;1:8—15. [13] Percival TJ, Rasmussen TE. Reperfusion strategies in the management of extremity vascular injury with ischaemia. Br J Surg 2012;1:66—74. [14] Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006;61:8—12. [15] Hornez E, Boddaert G, Ngabou UD, et al. Temporary vascular shunt for damage control of extremity vascular injury: a toolbox for trauma surgeons. J Visc Surg 2015;152(6):363—8. [16] DeBakey ME, Simeone MC. Battle injuries of the arteries in World War Two: an analysis of 2471 cases. Ann Surg 1946;123:534—79. [17] Percival TJ, White JM, Ricci MA. Compartment syndrome in the setting of vascular injury. Perspect Vasc Surg Endovasc Ther 2011;23(2):119—24. [18] Van Waes OJ, Cheriex KCAL, Navsaria PH, van Riet PA, Nicol AJ, Vermeulen J. Management of penetrating neck injuries. Br J Surg 2012;99:149—54. [19] Lee T, Ducic Y, Gordin E, Stroman D. Management of carotid artery trauma. Craniomaxillofacial Trauma Reconstr 2014;7:175—89. [20] Demetriades D, Asensio JA. Subclavian and axillary vascular injuries. Surg Clin North Am 2001;81:1357—73. [21] Sperry JL, Moore EE, Coimbra R, et al. Western Trauma Association Critical Decisions in Trauma: penetrating neck trauma. J Trauma Acute Care Surg 2013;75:936—40. [22] Gill H, Jenkins W, Edu S, Bekker W, Nicol AJ, Navsaria PH. Civilian penetrating axillary artery injuries. World J Surg 2011;35:962—6. [23] Berg RJ, Inaba K, Okoye O, et al. The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed. J Trauma Acute Care Surg 2014;77:684—91. [24] White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011;253:1184—9. [25] Lee JT, Bongard FS. Iliac vessel injuries. Surg Clin North Am 2002;82:21—48.