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Treatment of Penetrating Abdominal Wounds
Treatment of Penetrating Abdominal Wounds BENJAMIN H. GASTON, M.D.* JOHN H. MULHOLLAND, M.D., F.A.C.S.**
PENETRATING wounds of the abdomen result in considerable mortality and morbidity in both military and civilian experience. Statistics from reported series are not generally comparable. Varying mortality rates of: 35.9 per cent (McGowan, 1935),1 68 per cent (Prey and Foster, 1934),2 20= per cent (Imes, 1947),3 16.7 per cent (Bradford and Campbell, 1946)4 and 10.1 per cent (Sloan, 1944)5 reflect the improvement in therapy since 1939. 1.n inclusive discussion of the surgical probabilities created by the passage of wildly directed trauma is impossible. This is a field in which the surgeon must be guided by principles. Moreover, the bullet or the knife is totally unaware of the domains of surgery and anatomy established by specialty boards. Operative treatment of the penetrated abdomen is the most exacting test of the "general" surgeon. The guiding principles are established by experience. This paper will review, on the basis of such experience, principles which have been found useful. It will also illustrate by short abstracts of case histories instances of application and, unfortunately, sometimes lack of application, of the reasoning upon which a principle is based. ASSOCIATED WOUNDS
Abdominal wounds must be considered in relation to the patient as a whole. There are frequent associated wounds of the thorax, head, neck and extremities. Treatment of cardiorespiratory dysfunction caused by cardiac tamponade, pneumothorax, hemothorax, mediastinal shift or paradoxical respiration has precedence. Such treatment should not delay definitive treatment of the abdominal wound unduly. Whereas abdomiFrom the Third (New York Univermy) Surgical Divi8ion, BeUevue Hospital, New York, N. Y. * Instructor in Surgery, New York University CoUege of Medicine. ** Professor of Surgery, New York University CoUege of Medicine.
463
,. Benjamin H. Gaston, John H. Mulholland nal injury has precedence over definitive therapy of extremity injuries, usually some measures directed at extremities can be completed under the same anesthesia. DIAGNOSIS
All penetrating wounds between the shoulders and knees should be suspected of abdominal cavity involvement. Determination of this possibility is by (1) judging the path of bullet or knife by alignment of wounds of entry and exit, knowing the position of patient and assailant and type and length of knife or caliber of gun, and x-ray for foreign body or fracture which may indicate pathway and deflection of the missile, or by (2) evidence of intra-abdominal injury disclosed by physical examination, x-ray, urine examination, gastric aspiration, proctoscopy, etc. The optimum time to repair the damage in the abdomen is before there are overt signs. Therefore, if the possibility of penetration exists, operative exploration should be made. Wounds in which penetration of the abdominal cavity may be doubtful are knife stabs of the wall, the depth of which is indeterminate. In such cases limited exploration is preferable to probing the wound. An incision may be made near the stab wound through which the parietal peritoneum is inspected. Further exploration of the viscera is not required if this peritoneal layer is intact. This type of incision may be short but should be placed so that extension and full abdominal exploration can be carried out if necessary. MANDATORY PREOPERATIVE MEASURES
Penetrating abdominal wounds require urgent treatment. There is a direct relationship between time lapse from injury to operative treatment and morbidity and mortality. However, several procedures are necessary before the patient is operated upon. A large-caliber needle should be inserted into a vein and secured. The stomach should be emptied by tube, not only to provide against accidental aspiration but also because the presence or absence of blood in the stomach may be determined. The urine should be examined for evidence of injury to the urinary tract. Tetanus toxoid or antitoxin is administered. Antibiotics, usually both penicillin and streptomycin, are given intramuscularly. Blood in adequate quantities should be typed and cross-matched. HEMORRHAGE
The most ur"ent circumstance is intra-abdominal bleeding. Indications of continued hemorrhage are: (1) shock which does not respond to transfusion of whole blood or requires rapid, massive amounts to sustain response, and (2) temporary effect from transfusion with subsequent
Treatment of Penetrating Abdominal Wounds
465
relapse. Under these conditions immediate operation with ligation of the bleeding point is required. An illustration of such a case follows: CASE I (A.H., Bellevue Hospital 5556-53). A young man was admitted 72 hour after a stab wound of the right upper quadrant. His blood pressure was 60/40. The patient was given plasma and 500 cc. of Type 0 Rh-negative blood rapidly while blood was cross-matched. After an additional 500 cc. of crossmatched blood his blood pressure rose to 96/50. Operation was then begun while whole blood was administered under pressure. He was found to have over 2000 cc. of blood and clots in the peritoneal cavity from a severed right gastroepiploic artery. Hemostasis was secured and the blood pressure maintained during the remainder of the exploration which disclosed no further injuries.
Attempts to replace blood loss should not be prolonged but rather conducted simultaneously with operation. The magnitude of such loss may be catastrophic. The release of the tamponade provided by the intact abdominal wall along with the necessity of evacuating blood and clot to secure the bleeding point may require emergency measures. When some indication of the area which is bleeding is provided, grasping the main blood supply between the fingers may be life-saving. In extreme situations a hand across the abdominal aorta may provide a few moments during which some maneuvering is possible. In most instances this temporary block of blood flow must be accomplished above the origin of the celiac artery. At this site liver and kidney blood supply is interrupted and the danger of prolonging such interruption must be weighed against the threat of blood loss. It may be possible, for instance, during the moment provided, to determine that the superior mesenteric is the source of the bleeding in which case the root of the mesentery can be grasped, or in the case of the splenic artery the body of the pancreas. Most wounds of the aorta, iliac arteries and vena cava are fatal before the patient can be transported to a hospital. Occasionally, when the wound of the vessel wall is small and a confined retroperitoneal hematoma has limited bleeding, the posterior parietal peritoneum may be opened, the hematoma evacuated and the source of hemorrhage identified. A lumbar vessel can be ligated. A laceration of the aorta or vena cava may be repaired with arterial suture. A finger above and below the laceration to stop the bleeding will help. Most individual vessels in the abdomen can be ligated without danger. The hepatic artery, the portal vein and the superior mesenteric artery should be repaired if at all possible. When intestinal vessels are injured the area of bowel supplied by the vessel is observed for a period of time and if doubt as to viability exists resection should be done. Intramesenteric hematomas are approached cautiously. If the hematoma remains confined during observation and the arterial pulse distally is palpable, the hematoma can be left in place. If the hematoma enlarges or the bowel appears ischemic the
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Benjamin H. Gaston, John H. Mulholland
mesentery should be opened, hematoma evacuated and bleeding point ligated. ELECTIVE PREOPERATIVE MEASURES
In the absence of severe hemorrhage which requires immediate operation there is ample time for consideration of other factors which will aid in the management of the injury. X-ray films, carefully taken and studied, are justifiable time consumers. Even in the event of severe bleeding, films may be obtained expeditiously; certainly, when bleeding is not severe, x-ray is obligatory. Films of the chest and abdomen in the upright position, of the abdomen supine, and, if a foreign body is retained, a lateral view should be made. Information should be sought regarding air and blood in the pleural spaces, the position of the mediastinum, the size of the heart, coexisting pulmonary disease, free gas in the abdominal cavity, fractures of the ribs, vertebral column or pelvis, soft tissue shadows of the spleen, kidneys or liver and obliteration of the psoas shadow. The ordinary quickly obtained laboratory determinations of hemoglobin and white cells should be made. Further special procedures are decided upon with all the factors weighed in individual instances. These include proctoscopy, intravenous pyelography, cystography and other measures. PRINCIPLES OF OPERATIVE TECHNIQUE
At operation the wounds of entry and exit are regarded as an aid in deciding where to place the incision and are not used as a part of it. The first principle in all abdominal surgery applies with its greatest emphasis in this field. The incision should be liberal. The direction and position are dictated solely by the necessity for wide exposure. The operation is conducted on the principle that a thorough inspection of all possible injured areas is necessary. When the pathway of the missile is known, exploration of the fixed viscera can be modified accordingly. Mobile viscera on mesenteries should be completely explored even when the path of the missile is remote from the organ's position on the operating table. These parts are more easily dealt with than regions which are fixed or retroperitoneal. Of the latter, a most difficult space is the right upper quadrant where kidney, liver, colon, duodenum, bile ducts, pancreas and large vessels are crowded together. The following two abstracts are illustrative: CASE II (D.R., Bellevue Hospital 32769-52). A young man was seen 3 hours after having been shot in the right flank. The wound of exit was anteriorly at the left costal margin. Thus the bullet traversed from back to front in the right upper quadrant. At operation angentiallaceration of the anterior wall of the stomach was sutured. There was a moderate sized hematoma in the base of the right transverse mesocolon, but because of the innocent appearance of the colon,
Treatment of Penetrating Abdominal Wounds
J,.67
visible duodenum and surrounding peritoneum, this blood was not evacuated. The postoperative period was marked by paralytic ileus, which shortly thereafter was recognized to be the result of generalized peritonitis. Right pleural empyema, rapid deterioration and death followed. At autopsy a large retroperitoneal abscess was found to communicate with 2 perforations of the posterior wall of the ascending colon and 2 perforations of the retroperitoneal duodenum. CASE III (W.M., Bellevue Hospital 54111-51). A young man was seen 7 hours after having been shot in the right upper quadrant. The bullet went out the right lumbar region. At operation there was no fluid or evidence of leakage in the peritoneal cavity. A large hematoma of the right flank behind the colon was emptied and 3 perforations in the ascending colon and 1 in the hepatic flexure were found and closed. There were no postoperative difficulties and the patient was discharged 6 days later.
The error in the first case was due to a mistaken interpretation of the benign general appearance of the patient and the lack of intraperitoneal damage. Early in the course of such injuries this feature is disarming. A lapse of seven hours in the other case brought little general evidence of severe injury. The onset of ileus, distention and collapse may be sudden, and the opportunity for a good operation lost. A hematoma behind the right colon should be evacuated by a long incision in the right parietal peritoneum which permits mobilization of the colon, exposure of retroperitoneal structures and access to the posterior wall of the bowel. Similarly, when the blood collection is behind the hepatic flexure and duodenum a long peritoneal incision which will release the duodenum for mobilization medially so that the whole of the third portion of the duodenum can be explored must be made. The kidney and vena cava are then accessible for exploration. . The following case illustrates some principles involved in the treatment of wounds of the kidney and left colon: CASE IV (D.D., Bellevue Hospital 26132-52). A young man was admitted 30 minutes after a bullet pierced his abdomen from the left costal margin in the anterior axillary line to the right side of his back at the level of the third lumbar vertebra. His urine was bloody and there was a fracture of the left third lumbar transverse process. At operation a ragged laceration across the descending colon was repaired. Through a peritoneal incision which released splenic flexure and descending colon a large hematoma about the left kidney was cleared out revealing a torn lower pole. Bleeding from this site had ceased. Drains were placed at the kidney and brought out through the left flank. Because of destruction of bowel wall the repaired colon was exteriorized. Blood appeared in the urine for 2 days and red cells could be seen by microscope for several days more. Intravenous pyelography on the second day after operation disclosed no excretion by the left kidney, but when repeated on the eighteenth day showed normal concentration and excretion. In the meantime the wound healed in the exteriorized colon and the loop was replaced in the abdomen on the thirteenth day.
Comments on this case involve the kidney and grossly injured colon. In general the conservative treatment of the injured kidney is advisable.
468
Benjamin H. Gaston, John H. Mulholland
Nephrectomy should be performed only for dissolution, which is rare in penetrating wounds seen in peacetime injuries, or irreparable damage to the renal pelvis. Debridement and adequate drainage of the area which is wounded will often result, as in this patient, in restoration of function. The degree of injury to the colon is the factor upon which decisions as to management are made. In instances of badly torn, jagged or ischemic bowel wall, exteriorization of the loop is the safest procedure. Small colon lacerations can be closed. When the injured colon cannot be mobilized sufficiently to permit exteriorization a proximal diverting colostomy should be made. On the right side, the undesirability of a fluid ileostomy or cecostomy proximal to an ascending colon injury may make right hemicolectomy the procedure of choice. Damaged rectum is best managed by proximal diverting colostomy and retrorectal space drainage. Small bowel wounds are frequently multiple. They can be treated by inversion with purse-string or interrupted Lembert sutures, or, if concentrated within a short segment involving more than one-third of the circumference or associated with mesenteric damage, by resection and anastomosis. Continuity should always be re-established. Illustrative are the following cases: CASE V (W.M., Bellevue Hospital 70940-52). A young man was admitted following a gunshot wound of the right buttock and was found to have 8 perforations scattered through the small bowel. All were closed individually and he recovered promptlY. CASE VI (R.R., Bellevue Hospital 48716-53). A young man was admitted after receiving a gunshot wound of the right lower abdomen. At operation 8 perforations of the ileum within a 6 inch segment were found with an intramesenteric hematoma in the involved segment. Resection of the area and endto-end anastomosis was done. The subsequent course was uneventful.
In the following case, age and other complications are illustrated as factors in the outcome: CASE VII (M.S., Bellevue Hospital 41990-50). A 56 year old man was admitted 3 hours after multiple gunshot wounds had been inflicted. One bullet struck his left forearm and one entered the abdomen at the left costal margin and penetrated through to its exit in the back at the twelfth rib. Operation consisted of splenectomy for a through wound of the spleen, repair of 4 perforations of the jejunum, 1 laceration of the mesenteric border of the transverse colon and lacerations in the anterior and posterior walls of the stomach. Thus, in the straight course of the bullet from front to back transverse colon, 2 loops of jejunum, stomach and spleen were traversed. Shortly after operation, the patient became tremulous and wildly hallucinatory. He died on the third day. At autopsy all wounds were found sealed, there was no bleeding, and there were no further perforations.
Treatment of Penetrating Abdominal Wounds
469
Most patients with wounds resulting from such violence are young. In this patient his age and delirium tremens were factors in his death. The notable features of the case are: the multiplicity of injuries, the spleen injury for which splenectomy is indicated, and the fact that successful operation did not result in recovery. Wounds of the liver not only jeopardize the patient considerably but also are difficult to treat. When such a wound is encountered in which there is no active bleeding and the destruction of liver tissue is not great, such as might occur in a knife stab wound, nothing further than drainage need be done. Similarly, the path of a small caliber bullet may be irrigated and drained. Where there is fragmentation of liver tissue and extensive damage, arrest of bleeding and debridement must be accomplished. Sometimes helpful in hemostasis is the possibility of securing with fine clamps bleeding points on the surface of freshly cut liver. It may be possible to avoid the necessity of large mattress sutures, and at the same time sharply excise damaged tissue. The packing of absorbable gauze or sponges between mattress sutures should be avoided; certainly this method should be used only when the gravity of hemorrhage demands it. Wounds of smaller structures which are of importance are at times the most difficult to manage. Wounds of the bile ducts and the common hepatic artery require that some attempt at repair be made. The main pancreatic duct should be ligated and pancreas distal to the injury may be resected. Repair of injuries to the ureters should always be attempted primarily. If mobilization will permit end-to-end suture, a polyethylene catheter should be implanted snugly in the lumen and brought out to the exterior either through a nephrostomy or through the bladder. When a definitive step such as suture or reimplantation into the bladder is impossible, the proximal end should be exteriorized. A deliberate effort might be made at some later time to preserve the kidney. It is inadvisable to ligate the ureter under these circumstances. Bladder wounds require closure and provision for continuous bladder drainage. If the laceration is small and clean, continuous urethral catheter drainage is adequate. Suprapubic cystostomy should be done with more extensive injuries. SUMMARY
Certain guiding principles in the management of penetrating wounds of the abdomen may be summarized: 1. There are frequent associated injuries of the head, neck and thorax. First priority in treatment is to provide for and maintain an airway and respiratory exchange. 2. The treatment of penetrating wounds of the abdomen is operation and repair.
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Benjamin H. Gaston, John H. Mulholland
. 3. The direct and immediate method of treating severe hemorrhage from intra-abdominal vessels is ligation or repair of the vessel. 4. The incision in the abdominal wall is for exposure of all possible injuries. It should be ample. 5. In the patient who is not bleeding severely, preliminary measures, particularly x-ray films of the chest and abdomen, are essential. 6. Thorough exploration of the suspected path of the missile and of all mobile viscera even remote from the path must be made. 7. Even in the absence of intraperitoneal soiling or bleeding, retroperitoneal collections of blood which conceal the posterior wall of a hollow viscus should be removed and the viscus explored. 8. Wounds of the colon which involve destruction of tissue or avascularity should be treated by exteriorization of the loop. If exteriorization of such an area is not possible a proximal diverting colostomy or resection should be performed. 9. The small bowel should not be exteriorized; continuity should be established. 10. Wounds of the kidney should be treated conservatively. Nephrectomy should be performed only for massive dissolution or complete loss of blood supply. 11. Drainage should be employed in wounds of liver, pancreas or kidney. 12. Certain essential blood vessels should be repaired by suture or graft. 13. Responsibility for such patients is one of the gravest a surgeon assumes. It is a field which taxes the broad equipment of a "general" surgeon. REFERENCES 1. McGowan, F. J.: Penetrating Wounds of the Abdomen. Ann. Surg. 102: 395-408, 1935. 2. Prey, D. and Foster, J. M.: Gunshot Wounds of the Abdomen. Ann. Surg. 99: 265-270, 1934. 3. Imes, P. R.: Abdominal Trauma. Am. J. Surg. 73: 199-208, 1947. 4. Bradford, B. and Campbell, D. A.: Fatalities Following War Wounds of the Abdomen. Arch. Surg. 53: 414-424,1946. 5. Sloan, H. E.: Perforating Abdominal Injuries. Surg., Gynec. & Obst. 79: 337-341, 1944. 477 First Avenue New York 16, N. Y.
PENETRATING wounds of the abdomen result in considerable mortality and morbidity in both military and civilian experience. Statistics from reported series are not generally comparable. Varying mortality rates of: 35.9 per cent (McGowan, 1935),1 68 per cent (Prey and Foster, 1934),2 20= per cent (Imes, 1947),3 16.7 per cent (Bradford and Campbell, 1946)4 and 10.1 per cent (Sloan, 1944)5 reflect the improvement in therapy since 1939. 1.n inclusive discussion of the surgical probabilities created by the passage of wildly directed trauma is impossible. This is a field in which the surgeon must be guided by principles. Moreover, the bullet or the knife is totally unaware of the domains of surgery and anatomy established by specialty boards. Operative treatment of the penetrated abdomen is the most exacting test of the "general" surgeon. The guiding principles are established by experience. This paper will review, on the basis of such experience, principles which have been found useful. It will also illustrate by short abstracts of case histories instances of application and, unfortunately, sometimes lack of application, of the reasoning upon which a principle is based. ASSOCIATED WOUNDS
Abdominal wounds must be considered in relation to the patient as a whole. There are frequent associated wounds of the thorax, head, neck and extremities. Treatment of cardiorespiratory dysfunction caused by cardiac tamponade, pneumothorax, hemothorax, mediastinal shift or paradoxical respiration has precedence. Such treatment should not delay definitive treatment of the abdominal wound unduly. Whereas abdomiFrom the Third (New York Univermy) Surgical Divi8ion, BeUevue Hospital, New York, N. Y. * Instructor in Surgery, New York University CoUege of Medicine. ** Professor of Surgery, New York University CoUege of Medicine.
463
,. Benjamin H. Gaston, John H. Mulholland nal injury has precedence over definitive therapy of extremity injuries, usually some measures directed at extremities can be completed under the same anesthesia. DIAGNOSIS
All penetrating wounds between the shoulders and knees should be suspected of abdominal cavity involvement. Determination of this possibility is by (1) judging the path of bullet or knife by alignment of wounds of entry and exit, knowing the position of patient and assailant and type and length of knife or caliber of gun, and x-ray for foreign body or fracture which may indicate pathway and deflection of the missile, or by (2) evidence of intra-abdominal injury disclosed by physical examination, x-ray, urine examination, gastric aspiration, proctoscopy, etc. The optimum time to repair the damage in the abdomen is before there are overt signs. Therefore, if the possibility of penetration exists, operative exploration should be made. Wounds in which penetration of the abdominal cavity may be doubtful are knife stabs of the wall, the depth of which is indeterminate. In such cases limited exploration is preferable to probing the wound. An incision may be made near the stab wound through which the parietal peritoneum is inspected. Further exploration of the viscera is not required if this peritoneal layer is intact. This type of incision may be short but should be placed so that extension and full abdominal exploration can be carried out if necessary. MANDATORY PREOPERATIVE MEASURES
Penetrating abdominal wounds require urgent treatment. There is a direct relationship between time lapse from injury to operative treatment and morbidity and mortality. However, several procedures are necessary before the patient is operated upon. A large-caliber needle should be inserted into a vein and secured. The stomach should be emptied by tube, not only to provide against accidental aspiration but also because the presence or absence of blood in the stomach may be determined. The urine should be examined for evidence of injury to the urinary tract. Tetanus toxoid or antitoxin is administered. Antibiotics, usually both penicillin and streptomycin, are given intramuscularly. Blood in adequate quantities should be typed and cross-matched. HEMORRHAGE
The most ur"ent circumstance is intra-abdominal bleeding. Indications of continued hemorrhage are: (1) shock which does not respond to transfusion of whole blood or requires rapid, massive amounts to sustain response, and (2) temporary effect from transfusion with subsequent
Treatment of Penetrating Abdominal Wounds
465
relapse. Under these conditions immediate operation with ligation of the bleeding point is required. An illustration of such a case follows: CASE I (A.H., Bellevue Hospital 5556-53). A young man was admitted 72 hour after a stab wound of the right upper quadrant. His blood pressure was 60/40. The patient was given plasma and 500 cc. of Type 0 Rh-negative blood rapidly while blood was cross-matched. After an additional 500 cc. of crossmatched blood his blood pressure rose to 96/50. Operation was then begun while whole blood was administered under pressure. He was found to have over 2000 cc. of blood and clots in the peritoneal cavity from a severed right gastroepiploic artery. Hemostasis was secured and the blood pressure maintained during the remainder of the exploration which disclosed no further injuries.
Attempts to replace blood loss should not be prolonged but rather conducted simultaneously with operation. The magnitude of such loss may be catastrophic. The release of the tamponade provided by the intact abdominal wall along with the necessity of evacuating blood and clot to secure the bleeding point may require emergency measures. When some indication of the area which is bleeding is provided, grasping the main blood supply between the fingers may be life-saving. In extreme situations a hand across the abdominal aorta may provide a few moments during which some maneuvering is possible. In most instances this temporary block of blood flow must be accomplished above the origin of the celiac artery. At this site liver and kidney blood supply is interrupted and the danger of prolonging such interruption must be weighed against the threat of blood loss. It may be possible, for instance, during the moment provided, to determine that the superior mesenteric is the source of the bleeding in which case the root of the mesentery can be grasped, or in the case of the splenic artery the body of the pancreas. Most wounds of the aorta, iliac arteries and vena cava are fatal before the patient can be transported to a hospital. Occasionally, when the wound of the vessel wall is small and a confined retroperitoneal hematoma has limited bleeding, the posterior parietal peritoneum may be opened, the hematoma evacuated and the source of hemorrhage identified. A lumbar vessel can be ligated. A laceration of the aorta or vena cava may be repaired with arterial suture. A finger above and below the laceration to stop the bleeding will help. Most individual vessels in the abdomen can be ligated without danger. The hepatic artery, the portal vein and the superior mesenteric artery should be repaired if at all possible. When intestinal vessels are injured the area of bowel supplied by the vessel is observed for a period of time and if doubt as to viability exists resection should be done. Intramesenteric hematomas are approached cautiously. If the hematoma remains confined during observation and the arterial pulse distally is palpable, the hematoma can be left in place. If the hematoma enlarges or the bowel appears ischemic the
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Benjamin H. Gaston, John H. Mulholland
mesentery should be opened, hematoma evacuated and bleeding point ligated. ELECTIVE PREOPERATIVE MEASURES
In the absence of severe hemorrhage which requires immediate operation there is ample time for consideration of other factors which will aid in the management of the injury. X-ray films, carefully taken and studied, are justifiable time consumers. Even in the event of severe bleeding, films may be obtained expeditiously; certainly, when bleeding is not severe, x-ray is obligatory. Films of the chest and abdomen in the upright position, of the abdomen supine, and, if a foreign body is retained, a lateral view should be made. Information should be sought regarding air and blood in the pleural spaces, the position of the mediastinum, the size of the heart, coexisting pulmonary disease, free gas in the abdominal cavity, fractures of the ribs, vertebral column or pelvis, soft tissue shadows of the spleen, kidneys or liver and obliteration of the psoas shadow. The ordinary quickly obtained laboratory determinations of hemoglobin and white cells should be made. Further special procedures are decided upon with all the factors weighed in individual instances. These include proctoscopy, intravenous pyelography, cystography and other measures. PRINCIPLES OF OPERATIVE TECHNIQUE
At operation the wounds of entry and exit are regarded as an aid in deciding where to place the incision and are not used as a part of it. The first principle in all abdominal surgery applies with its greatest emphasis in this field. The incision should be liberal. The direction and position are dictated solely by the necessity for wide exposure. The operation is conducted on the principle that a thorough inspection of all possible injured areas is necessary. When the pathway of the missile is known, exploration of the fixed viscera can be modified accordingly. Mobile viscera on mesenteries should be completely explored even when the path of the missile is remote from the organ's position on the operating table. These parts are more easily dealt with than regions which are fixed or retroperitoneal. Of the latter, a most difficult space is the right upper quadrant where kidney, liver, colon, duodenum, bile ducts, pancreas and large vessels are crowded together. The following two abstracts are illustrative: CASE II (D.R., Bellevue Hospital 32769-52). A young man was seen 3 hours after having been shot in the right flank. The wound of exit was anteriorly at the left costal margin. Thus the bullet traversed from back to front in the right upper quadrant. At operation angentiallaceration of the anterior wall of the stomach was sutured. There was a moderate sized hematoma in the base of the right transverse mesocolon, but because of the innocent appearance of the colon,
Treatment of Penetrating Abdominal Wounds
J,.67
visible duodenum and surrounding peritoneum, this blood was not evacuated. The postoperative period was marked by paralytic ileus, which shortly thereafter was recognized to be the result of generalized peritonitis. Right pleural empyema, rapid deterioration and death followed. At autopsy a large retroperitoneal abscess was found to communicate with 2 perforations of the posterior wall of the ascending colon and 2 perforations of the retroperitoneal duodenum. CASE III (W.M., Bellevue Hospital 54111-51). A young man was seen 7 hours after having been shot in the right upper quadrant. The bullet went out the right lumbar region. At operation there was no fluid or evidence of leakage in the peritoneal cavity. A large hematoma of the right flank behind the colon was emptied and 3 perforations in the ascending colon and 1 in the hepatic flexure were found and closed. There were no postoperative difficulties and the patient was discharged 6 days later.
The error in the first case was due to a mistaken interpretation of the benign general appearance of the patient and the lack of intraperitoneal damage. Early in the course of such injuries this feature is disarming. A lapse of seven hours in the other case brought little general evidence of severe injury. The onset of ileus, distention and collapse may be sudden, and the opportunity for a good operation lost. A hematoma behind the right colon should be evacuated by a long incision in the right parietal peritoneum which permits mobilization of the colon, exposure of retroperitoneal structures and access to the posterior wall of the bowel. Similarly, when the blood collection is behind the hepatic flexure and duodenum a long peritoneal incision which will release the duodenum for mobilization medially so that the whole of the third portion of the duodenum can be explored must be made. The kidney and vena cava are then accessible for exploration. . The following case illustrates some principles involved in the treatment of wounds of the kidney and left colon: CASE IV (D.D., Bellevue Hospital 26132-52). A young man was admitted 30 minutes after a bullet pierced his abdomen from the left costal margin in the anterior axillary line to the right side of his back at the level of the third lumbar vertebra. His urine was bloody and there was a fracture of the left third lumbar transverse process. At operation a ragged laceration across the descending colon was repaired. Through a peritoneal incision which released splenic flexure and descending colon a large hematoma about the left kidney was cleared out revealing a torn lower pole. Bleeding from this site had ceased. Drains were placed at the kidney and brought out through the left flank. Because of destruction of bowel wall the repaired colon was exteriorized. Blood appeared in the urine for 2 days and red cells could be seen by microscope for several days more. Intravenous pyelography on the second day after operation disclosed no excretion by the left kidney, but when repeated on the eighteenth day showed normal concentration and excretion. In the meantime the wound healed in the exteriorized colon and the loop was replaced in the abdomen on the thirteenth day.
Comments on this case involve the kidney and grossly injured colon. In general the conservative treatment of the injured kidney is advisable.
468
Benjamin H. Gaston, John H. Mulholland
Nephrectomy should be performed only for dissolution, which is rare in penetrating wounds seen in peacetime injuries, or irreparable damage to the renal pelvis. Debridement and adequate drainage of the area which is wounded will often result, as in this patient, in restoration of function. The degree of injury to the colon is the factor upon which decisions as to management are made. In instances of badly torn, jagged or ischemic bowel wall, exteriorization of the loop is the safest procedure. Small colon lacerations can be closed. When the injured colon cannot be mobilized sufficiently to permit exteriorization a proximal diverting colostomy should be made. On the right side, the undesirability of a fluid ileostomy or cecostomy proximal to an ascending colon injury may make right hemicolectomy the procedure of choice. Damaged rectum is best managed by proximal diverting colostomy and retrorectal space drainage. Small bowel wounds are frequently multiple. They can be treated by inversion with purse-string or interrupted Lembert sutures, or, if concentrated within a short segment involving more than one-third of the circumference or associated with mesenteric damage, by resection and anastomosis. Continuity should always be re-established. Illustrative are the following cases: CASE V (W.M., Bellevue Hospital 70940-52). A young man was admitted following a gunshot wound of the right buttock and was found to have 8 perforations scattered through the small bowel. All were closed individually and he recovered promptlY. CASE VI (R.R., Bellevue Hospital 48716-53). A young man was admitted after receiving a gunshot wound of the right lower abdomen. At operation 8 perforations of the ileum within a 6 inch segment were found with an intramesenteric hematoma in the involved segment. Resection of the area and endto-end anastomosis was done. The subsequent course was uneventful.
In the following case, age and other complications are illustrated as factors in the outcome: CASE VII (M.S., Bellevue Hospital 41990-50). A 56 year old man was admitted 3 hours after multiple gunshot wounds had been inflicted. One bullet struck his left forearm and one entered the abdomen at the left costal margin and penetrated through to its exit in the back at the twelfth rib. Operation consisted of splenectomy for a through wound of the spleen, repair of 4 perforations of the jejunum, 1 laceration of the mesenteric border of the transverse colon and lacerations in the anterior and posterior walls of the stomach. Thus, in the straight course of the bullet from front to back transverse colon, 2 loops of jejunum, stomach and spleen were traversed. Shortly after operation, the patient became tremulous and wildly hallucinatory. He died on the third day. At autopsy all wounds were found sealed, there was no bleeding, and there were no further perforations.
Treatment of Penetrating Abdominal Wounds
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Most patients with wounds resulting from such violence are young. In this patient his age and delirium tremens were factors in his death. The notable features of the case are: the multiplicity of injuries, the spleen injury for which splenectomy is indicated, and the fact that successful operation did not result in recovery. Wounds of the liver not only jeopardize the patient considerably but also are difficult to treat. When such a wound is encountered in which there is no active bleeding and the destruction of liver tissue is not great, such as might occur in a knife stab wound, nothing further than drainage need be done. Similarly, the path of a small caliber bullet may be irrigated and drained. Where there is fragmentation of liver tissue and extensive damage, arrest of bleeding and debridement must be accomplished. Sometimes helpful in hemostasis is the possibility of securing with fine clamps bleeding points on the surface of freshly cut liver. It may be possible to avoid the necessity of large mattress sutures, and at the same time sharply excise damaged tissue. The packing of absorbable gauze or sponges between mattress sutures should be avoided; certainly this method should be used only when the gravity of hemorrhage demands it. Wounds of smaller structures which are of importance are at times the most difficult to manage. Wounds of the bile ducts and the common hepatic artery require that some attempt at repair be made. The main pancreatic duct should be ligated and pancreas distal to the injury may be resected. Repair of injuries to the ureters should always be attempted primarily. If mobilization will permit end-to-end suture, a polyethylene catheter should be implanted snugly in the lumen and brought out to the exterior either through a nephrostomy or through the bladder. When a definitive step such as suture or reimplantation into the bladder is impossible, the proximal end should be exteriorized. A deliberate effort might be made at some later time to preserve the kidney. It is inadvisable to ligate the ureter under these circumstances. Bladder wounds require closure and provision for continuous bladder drainage. If the laceration is small and clean, continuous urethral catheter drainage is adequate. Suprapubic cystostomy should be done with more extensive injuries. SUMMARY
Certain guiding principles in the management of penetrating wounds of the abdomen may be summarized: 1. There are frequent associated injuries of the head, neck and thorax. First priority in treatment is to provide for and maintain an airway and respiratory exchange. 2. The treatment of penetrating wounds of the abdomen is operation and repair.
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Benjamin H. Gaston, John H. Mulholland
. 3. The direct and immediate method of treating severe hemorrhage from intra-abdominal vessels is ligation or repair of the vessel. 4. The incision in the abdominal wall is for exposure of all possible injuries. It should be ample. 5. In the patient who is not bleeding severely, preliminary measures, particularly x-ray films of the chest and abdomen, are essential. 6. Thorough exploration of the suspected path of the missile and of all mobile viscera even remote from the path must be made. 7. Even in the absence of intraperitoneal soiling or bleeding, retroperitoneal collections of blood which conceal the posterior wall of a hollow viscus should be removed and the viscus explored. 8. Wounds of the colon which involve destruction of tissue or avascularity should be treated by exteriorization of the loop. If exteriorization of such an area is not possible a proximal diverting colostomy or resection should be performed. 9. The small bowel should not be exteriorized; continuity should be established. 10. Wounds of the kidney should be treated conservatively. Nephrectomy should be performed only for massive dissolution or complete loss of blood supply. 11. Drainage should be employed in wounds of liver, pancreas or kidney. 12. Certain essential blood vessels should be repaired by suture or graft. 13. Responsibility for such patients is one of the gravest a surgeon assumes. It is a field which taxes the broad equipment of a "general" surgeon. REFERENCES 1. McGowan, F. J.: Penetrating Wounds of the Abdomen. Ann. Surg. 102: 395-408, 1935. 2. Prey, D. and Foster, J. M.: Gunshot Wounds of the Abdomen. Ann. Surg. 99: 265-270, 1934. 3. Imes, P. R.: Abdominal Trauma. Am. J. Surg. 73: 199-208, 1947. 4. Bradford, B. and Campbell, D. A.: Fatalities Following War Wounds of the Abdomen. Arch. Surg. 53: 414-424,1946. 5. Sloan, H. E.: Perforating Abdominal Injuries. Surg., Gynec. & Obst. 79: 337-341, 1944. 477 First Avenue New York 16, N. Y.