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Intra-abdominal injuries of the bowel, mesentery, and mesenteric vessels were found at laparotomy in two patients with nonpenetrating gunshot wounds of the abdominal wall. The mechanism of wounding is thought to be the temporary cavity around the wound tract. The importance of complete angiographic investigation and early exploratory laparotomy is stressed.
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Injuries of the retroperitoneal organs occur mainly in patients with multiple traumas. Spine and spinal muscle provide an effective protection against blunt trauma from behind. In the front the thin peritoneal layer is just a biological border. Therefore injuries of the abdominal and retroperitoneal organs frequently occur together. Direct clinical examinations are limited by the specific anatomical situation; further invasive diagnostic procedures deal mainly with indirect effects of retroperitoneal injuries. Massive hemorrhage with consequent retroperitoneal hematoma is the dominant pathophysiologic course; mortality is high.
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The radiologic findings in blunt and penetrating splenic injuries are discussed with emphasis on the angiographic demonstration of these injuries. The angiographic findings are correlated with the time interval between trauma and radiologic investigation.
Laparoscopy was evaluated in thirty-seven patients from a group of 132 consecutive patients who were treated for blunt or penetrating injury to the abdomen. A total of twenty-three patients underwent laparoscopy and laparotomy. The findings at laparotomy correlated with laparoscopy. Fourteen patients underwent laparoscopy only, and there were no proved false-negative results. Of the 132 patients considered for laparotomy, 118 underwent abdominal exploration. Laparotomy was considered unnecessary in twenty-five of the 118 patients (21 per cent) and in retrospect, laparoscopy could have identified in each patient the presence of a minor injury or no injury at all. Laparoscopy is a useful method for evaluating blunt and penetrating injuries to the abdomen in selected patients.
Injuries to the inferior vena cava are being seen with increasing frequency in the civilian population. A review of the experience at UCLA/Harbor General Hospital Medical Center over a ten year period (1966 to 1976) discloses thirty-four patients with major injuries to the inferior vena cava, with an overall mortality of 53%. The factors that appear critical to patient survival are: (1) level of injury (suprarenal versus infrarenal sites); (2) presence or absence of profound shock on admission; and (3) the speed with which diagnosis is made and treatment carried out. Technical considerations regarding identification and handling of inferior vena caval injuries are presented. The mortality rate for major inferior vena caval injuries remains distressingly high and serves as a challenge for future improvement.
Subclavian and innominate arterial injuries are life-threatening and require aggressive treatment. Physical findings, chest x-ray examinations, and a high index of suspicion led to expoloration in seventeen of twenty-two patients in this series, but the selective use of arteriography is helpful. Primary repair was accomplished in nineteen of the twenty-two patients. Wide proximal exposure proved to be accompanied by little morbidity with the reward of increasing survival to 95.5 per cent.
Fifty patients having undergone operation for injury to the abdominal aorta and/or vena cava at the University of Alabama Hospital are reviewed. Factors influencing mortality include mechanism and location of injury, presence of shock, associated vascular and visceral organ injuries, and delay in treatment. Rapid restoration of blood volume and control of hemorrhage are the primary goals of resuscitative measures. Only with a preconceived and coordinated plan can the surgeon fully employ the necessary skills in the management of these serious injuries.
Despite immediate operation, patients with abdominal aortic injuries and profound hypovolemic shock do not respond to the usual methods of resuscitation and die soon after celiotomy, prior to control and repair of the aortic injury. The rate of aortic hemorrhage exceeds the ability to restore blood volume. Shock becomes "irreversible." In such patients tamponade of the aortic injury may be effected by the use of an external counterpressure device such as a G-suit or MAST suit. These devices, used in conjunction with transthoracic aortic occlusion, may raise blood pressure sufficiently to perfuse the sritical coronary and cerebral circulation, allowing time to correct acidosis and locate, control, and repair the aortic injury. Early aggressive therapy should result in increased survival.
From 1968 to 1978, 14 patients were treated for major tracheal or bronchial injury. Five injuries resulted from blunt trauma and nine from penetrating injury. Of the 5 patients with injury due to blunt trauma, three had avulsions of the right main bronchus from the trachea. In 2 of them, the injury was associated with stellate tears of the distal trachea and bronchus. The simple avulsion was repaired by a primary anastomosis of the right main bronchus to the distal trachea. For the other 2 patients, treatment consisted of right pneumonectomy. The remaining 2 patients in this group had complete transection of the trachea and underwent primary repair. Of the 9 patients with a penetrating injury, 4 had lacerations of the cervical trachea which were treated with neck exploration and tracheostomy. Three patients with partial transections of the cervical or upper mediastinal trachea were treated by primary closure. The other 2 patients had gunshot wounds to the distal right lateral trachea, which were treated by right thoracotomy and primary closure. There were no deaths, and the subsequent course was generally good in all patients.
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The pertinent literature on renal trauma for the last 25 years has been analyzed. An evolutionary pattern is seen in the development of diagnostic methods, while surgical and medical management of renal trauma has become much more precise for specific lesions. Various subareas of interest within the field have emerged, such as pediatric trauma, associated injuries and the subdivisions of blunt and penetrating trauma. Furthermore, therapy has been extended to include those severe vascular lesions that previously were considered untreatable. Various new and experimental concepts are described. Specific recommendations regarding the diagnosis and the therapeutic management are offered in an attempt to bring perspective to these new developments.
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The spectrum of genitourinary injuries seen in a small community hospital over the past three years is presented. With the exception of the obvious ureteral injury, the key factor in management is adequate x-ray diagnosis. This allows the physician to estimate the type and extent of injury. In the clinically stable patient, renal injuries can be managed conservatively. However, in our experience a major renal injury is usually associated with major intra-abdominal injury and these patients require exploration. Bladder injuries may be diagnosed with a cystogram, and repaired. Posterior urethral injuries may be managed initially by simple insertion of a suprapubic tube.
Reports of advancements in emergency department operative resuscitative skills have included craniotomy, thoracotomy, cardiorrhaphy and even cardiopulmonary bypass. The efficacy and advisability of laparotomy in the emergency department remain in question. Between July, 1972, and July, 1977, adhering to an established protocol, resuscitative laparotomy was performed on 51 patients in the emergency department. All 51 patients underwent emergency thoracotomy also. Twenty-four patients were victims of gunshot wounds, 24 had sustained blunt trauma, and three had abdominal stab wounds. Injuries to the liver, major vessels, and spleen were most common. Control of hemorrhage by clamps, packs or pressure was the primary objective of laparotomy. Control of exsanguinating hemorrhage with precise application of vascular clamps was possible in all but 15 patients. Because of extensive multiple injuries and inability to achieve cardiovascular stability, only 11 patients reached the operating room, and none survived to leave the hospital. Although technically possible, laparotomy in the emergency center did not alter the fatal outcome of moribund patients in this series.