|Year : 2019 | Volume
| Issue : 2 | Page : 139-144
Penetrating abdominal injuries due to firearms in combat zone – Single center experience
AK Sharma1, Vivek Agrawal2, Abhijeet Lal3, Abhimannyu Choudhury4, Pallab Chatterjee5, Manomoy VSM Ganguly6
1 Department of Surgical Gastroenterology, Army Hospital (Research & Referral), Delhi, India
2 Department of Vascular Surgery, Army Hospital (Research & Referral), Delhi Cantonment, Delhi, India
3 Classified Specialist (Surgery), 15 Air Force Hospital, Jodhpur, Rajasthan, India
4 Classified Specialist (Surgery), Military Hospital Namkum, Ranchi, Jharkhand, India
5 Department of Plastic Surgery, Army Hospital (Research & Referral), Delhi Cantonment, Delhi, India
6 Surgical Oncologist, Ex-DGMS (Army), New Delhi, India
|Date of Submission||13-Feb-2019|
|Date of Acceptance||05-Jun-2019|
|Date of Web Publication||07-Oct-2019|
Dr. Vivek Agrawal
Department of Vascular Surgery, Army Hospital (Research and Referral), New Delhi - 110 010
Source of Support: None, Conflict of Interest: None
Background: Abdominal trauma is a frequent indication for surgical exploration of the combat causality. Rapid transportation to trauma center, early recognition of injuries, sound surgical judgment, and timely intervention are critical for reducing mortality and morbidity. Patients and Methods: All penetrating abdominal trauma (PAT) cases admitted to a combat zone hospital from January 2014 to December 2016 were studied. Results: Forty-eight patients with PAT were evaluated and managed. Majority (66.7%) were secondary to gunshot injuries. Forty-one required operative management. Out of these, 6 (12.5%) underwent diagnostic laparoscopy and 35 (72.9%) required laparotomy. The small intestine was the most commonly injured organ which was encountered in 21 (43.7%) cases. Two (4.2%) patients succumbed to their injuries. Early resuscitation in combat zone followed by prompt evacuation to the combat hospital improved the overall outcome. Conclusion: PAT is a common cause of morbidity and mortality in combat areas. Rapid transportation, sound clinical judgment, and early surgical intervention are critical for patient survival and better outcomes.
Keywords: Combat zone, damage control surgery, focused assessment by sonography for trauma, penetrating abdominal trauma
|How to cite this article:|
Sharma A K, Agrawal V, Lal A, Choudhury A, Chatterjee P, Ganguly M. Penetrating abdominal injuries due to firearms in combat zone – Single center experience. J Mar Med Soc 2019;21:139-44
|How to cite this URL:|
Sharma A K, Agrawal V, Lal A, Choudhury A, Chatterjee P, Ganguly M. Penetrating abdominal injuries due to firearms in combat zone – Single center experience. J Mar Med Soc [serial online] 2019 [cited 2019 Dec 9];21:139-44. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/2/139/268635
| Introduction|| |
Penetrating abdominal trauma (PAT) remains the second most common emergency after lower limb injuries in combat zone. PAT is commonly associated with injuries to other body parts. PAT may be missed due to altered mental status secondary to head trauma, subtle symptoms and signs and lack of historical information. If not identified and treated in time, it may result in fatal outcome. Focused assessment by sonography for trauma (FAST) and computed tomography (CT) scans helps in the rapid assessment. The time interval from injury to control of hemorrhage is the dominant variable defining patient survival.,, Over the last two decades, greater understanding of permissive hypotension and damage control surgery has proved very useful  in the successful salvage of severely injured patients. Immediate resuscitation, rapid evacuation, early intervention, and advances in anesthesia have also contributed to improved survival.
| Patients and Methods|| |
Patients admitted in a combat hospital from January 2014 to November 2016 with PAT were prospectively studied. Patients after initial resuscitation and triage were evacuated either by air or road. Relevant X-rays, FAST, and other necessary imaging were carried out. Unstable patients were taken for immediate surgery during/after resuscitation, while stable patients were further investigated and observed.
Patients were categorized into three groups:
- Hemodynamically unstable patients with peritonism (rigidity/guarding of abdomen and absent bowel sounds), who needed immediate surgery
- Hemodynamically stable patients with equivocal signs of peritonism, who were evaluated with diagnostic laparoscopy
- Nonoperative management (NOM) group consisting of hemodynamically stable without peritonitis. Need for surgical exploration was considered if the patients of NOM became hemodynamically unstable or developed relevant clinical signs.
The study included demographic data, mechanism of injuries, prehospital care, and time elapsed in reaching the combat hospital. Analysis of associated injuries, investigations performed, procedures done, requirement of transfusion of blood, duration of admission, and surgical outcomes were carried out. Brought in dead patients were excluded from the study.
| Results|| |
The observations and the results are summarized in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]. In 3 years, 580 trauma patients were brought to trauma center of the combat hospital, out of which 48 suffered PAT. Out of 48 PAT cases, 32 (66.7%) had gunshot wound (GSW) and 16 (33.3%) had injuries due to grenade blast. Time elapsed from injury to reaching hospital ranged from 3 to 14 h with a mean of 7 h. Evacuation time was influenced by hostile environment, hilly terrain, availability of means of evacuation, unfavorable weather conditions, etc.
|Table 4: Findings of intra-abdominal injuries found on exploratory laparotomy|
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All patients were male with median age of 23 years (range 19–46 years) [Table 1]. Out of 48 PAT patients, 27 (56.3%) had additional injuries to the limbs, chest, head, and neck region [Table 2]. Eight (16.7%) patients reached in a state of hemorrhagic shock.
FAST was done for 40 patients (83.3%), whereas CT scan was done for 18 patients (37.5%) depending on the clinical status of the patients on reaching the hospital.
Thirty-five patients (72.9%) were taken up for emergency laparotomy on presentation, 6 patients (12.5%) were considered for diagnostic laparoscopy and remaining 7 patients (14.6%) were managed conservatively [Table 3]. Out of 6 patients who underwent diagnostic laparoscopy, 2 patients were found to have hemoperitoneum necessitating immediate conversion to open surgery.
In the laparotomy group of 37 patients (35 initial laparotomies and 2 conversions from diagnostic laparoscopy), most patients had multiple hollow viscus and solid-organ injuries [Table 4].
The most common injury encountered was perforation of the small intestine in 21 patients (43.7%). In 16 cases, one to three rents were found without significant peritoneal soiling. These cases were treated with primary repair. Out of these, 13 cases had uneventful recovery, but 3 cases developed signs of leak in form of peritonitis in the postoperative period. These three patients underwent reexploration with resection and ileostomy. Three cases with laceration of small portion of small intestine without significant peritoneal soiling underwent resection and anastomosis, while one case with laceration of intestine with peritoneal soiling needed resection and ileostomy. We had five cases of colonic laceration with peritoneal soiling. All these cases underwent resection, end colostomy with mucous fistula. Restoration of continuity of gut was done after 3–6 months in patients with ileostomy and colostomy. No patient developed enterocutaneous fistula in a follow-up ranging from 6 months to 2 years [Table 5].
Nine patients had evidence of solid organ injuries, equally distributed among the liver, spleen, and kidney [Table 4]. In three patients with liver laceration, bleeding was controlled by cautery and suturing. Out of three patients with splenic injuries, two patients had Grade 4 laceration requiring splenectomy, while in one patient with Grade 2 splenic laceration underwent suture splenorrhaphy. Three patients sustained Grade 4/Grade 5 laceration of the kidney with hemorrhage that required emergency nephrectomy to salvage the patients. These three patients reached the hospital in shock with signs of peritonitis. They were too unstable for any preliminary investigations like CT scan and were taken up for immediate emergency laparotomy. They had other concomitant bleeding sites with intestinal/mesenteric rents along with Grade 4/Grade 5 renal injury. The only way to salvage these patients was to arrest the hemorrhage with nephrectomy. On table single-shot intravenous urography to assess the contralateral kidney was not done. However, the contralateral kidney was clinically examined as a part of exploratory laparotomy was done and found to be intact in these three patients. CT scan was done during the postoperative recovery period if indicated.
Six patients (12.5%) had vascular injuries. Blood requirements varied from nil to 24 units with a mean of 3 units. The most common complication was superficial surgical site infection and ventilator-associated pneumonia which was seen in 6 cases (12.5%) [Table 6]. Four casualties required multiple surgeries because of wound dehiscence, anastomotic leak, sepsis, or colostomy/ileostomy closures. Two patients with multiple injuries in the liver, spleen, aorta, and inferior vena cava (IVC) succumbed to their injuries.
Hospital stay ranged from 9 to 39 days (median 14 days). Patients who could be evacuated early from combat zone had better outcomes. Patients with shock required more blood transfusions, had more complications, had prolonged recovery period, and two such casualties presenting with shock succumbed to their injuries. Patients with large intestine injury and fecal soiling of peritoneal cavity benefitted with proximal colostomy or enterostomy of gut. Patients with small intestine injuries in the absence of fecal soiling were managed by primary repair.
| Discussion|| |
Expectant management was the approach of choice worldwide for PAT till the 19th century and was associated with overwhelming morbidity/mortality. Dr. Marion Simms, President of the American Medical Association, advocated mandatory exploration leading to decrease in mortality from World War I (53%), World War II (24%), the Korean conflict (12%), and the Vietnam War (9%). Shafton and Nance emphasized the shift from mandatory to selective celiotomy.,,
In our study, majority of the patients (85.4%) required surgical intervention. Out of the six patients taken up for diagnostic laparoscopy, two needed conversion to laparotomy as one patient had biliary soiling due to proximal ileal injury and the other patient had hemoperitoneum due to liver laceration. Seven patients who were hemodynamically stable, had no signs of peritonism, and had negative FAST exam were managed conservatively. This is different from noncombat scenario where more patients with PAT can be managed conservatively. The pattern of penetrating abdominal injuries in combat zone due to GSWs is different from the ones caused by stab wounds seen in civilian, noncombat scenario. We recommend very close monitoring for patients undergoing nonoperative treatment and low threshold for exploration in case of clinical deterioration for PAT patients in combat zone.
War wounds create wider damage due to higher velocity, cavitatory effect, and jagged splinters. Limbs and pelvis are the most frequently injured parts. Abdominal and thoracic lesions have higher mortality in trauma victims. Polytrauma deaths are usually caused by cranial injuries in 40%–50%, by hemorrhage in 30%–35%, and by multiple organ failure in 5%–10% of cases. Two mortalities in the study were due to profound hemorrhagic shock following multiple intra-abdominal injuries with aortic injuries.
Kristensen et al. introduced FAST in emergency for evaluation of hemoperitoneum. Rozycki et al. reported that FAST is an accurate modality for detecting fluid in the pericardial sac., Sensitivity and negative predictive value for hemoperitoneum are 78%–99% and 93–99%, respectively. FAST is mandatory for detection of pericardial hemorrhage (i.e., cardiac injury).,, In our study, it was the investigation of choice and was done in 40 cases. We recommend using FAST as the part of the initial assessment on the presentation of the patients. Hauser et al. recommended “triple-contrast” CT for penetrating injuries of back and flank. It is an essential diagnostic tool for selective management of PAT obviating the need for mandatory surgical exploration. It is selectively used for stable patients. Detection of intestinal perforation and diaphragmatic injury may be the two major limitations of CT scan. In our study, CT scan was performed in 18 cases and contributed significantly to decision-making.
Diagnostic laparoscopy was introduced as a possible diagnostic and therapeutic procedure by Ivatury et al. for PAT. We performed it for six cases with equivocal signs of peritonism, out of which two were positive with hemoperitoneum and biliary leak and were converted to formal laparotomy. On laparotomy, one patient was found to have liver laceration in which hemostasis was achieved by application of direct pressure, Surgicel and minimal use of Monopolar cautery, while the other patient with biliary soiling was detected to have two small rents in the proximal ileum which were repaired primarily.
Urgent laparotomy is mandatory for hemodynamic instability, gross peritoneal signs, and evisceration., If PAT presents with evisceration, signs of peritonism or hemodynamic instability, it requires urgent surgery. In our study, six patients had evisceration of omentum/small intestine and underwent urgent surgery.
Abdominal exploration for trauma has four goals – (i) hemorrhage control, (ii) contamination control, (iii) identification of injury, and (iv) its repair/reconstruction. After the major hemorrhage is controlled, blood and blood clots are removed and abdominal packing is done to provide tamponade and achieve hemostasis [Figure 1]. In PAT patients with signs of peritonitis, even if they are stable, need exploratory laparotomy [Figure 2].
|Figure 1: Preoperative packing with operation theatre towel. Often, in the face of continued bleeding after opening the abdomen, packing the peritoneal cavity for 10–15 min allows accurate localization of the bleeding area|
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|Figure 2: Entry wound of gunshot wound right side of the umbilicus. The wound looks may appear innocuous and the patient may be stable on presentation. However, most of these patients will require exploratory laparotomy|
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In our study, three cases had rents in the stomach that were all repaired primarily without any subsequent complications. Isolated small bowel perforations can be closed primarily [Figure 3]. However, multiple contiguous small bowel rents or injury on the mesenteric border with associated mesenteric hematoma generally necessitates segmental resection and anastomosis. In our study, in 16 cases, small intestinal perforations were repaired primarily, whereas three patients underwent segmental resection and anastomosis as the initial procedure. Two cases had multiple contiguous rents in distal small intestine with gross soiling. They underwent segmental resection followed by creation of ileostomies with mucous fistulas.
|Figure 3: Primary repair of intestine and mesentery. The exploration of the abdomen of the patient in Figure 2 showed multiple rents in the small intestine and the mesentery in spite of the patient being stable on presentation. If minimal peritoneal soiling is present, these rents can be safely repaired primarily|
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An injury of the colon can be treated by various procedures such as primary closure, resection and anastomosis, proximal colostomy and mucous fistula, or Hartmann's procedure. We had five cases involving large intestinal injury with spillage. All cases underwent resection of large intestine and colostomy with mucous fistula. Restoration of gut continuity was performed after 3–6 months postprimary surgery.
Rents in the diaphragm should be closed to prevent contamination of the thoracic cavity as well as possible diaphragmatic hernias. We found diaphragmatic rent in three cases all of which were repaired primarily after placing chest tubes.
Most penetrating splenic injuries require a splenectomy. Superficial penetrating injuries of the spleen can be managed by either splenorrhaphy or application of topical hemostatic agent. We had two cases that required splenectomy and one case of splenic injury could be managed with splenorrhaphy. Liver injuries are common in both blunt and penetrating trauma. Majority of injuries are superficial or minor and require simple application of pressure, hemostatic agent, or fibrin glue only. The argon beam coagulator is also a helpful adjunct. We had two cases of penetrating liver injuries which could be managed with application of pledgeted sutures.
Penetrating renal injuries that result in a Grade IV (cortical/calyceal injury and associated vascular injury with contained hemorrhage) or Grade V (shattered kidney and vascular avulsion) invariably necessitate a nephrectomy if there is a viable and functional contralateral kidney. We had three cases of Grade IV/V renal injury that required emergency nephrectomies.
Retroperitoneum is divided into three zones. Zone 1 is central – comprising abdominal aorta, celiac axis, superior mesenteric artery, vena cava, and proximal renal vasculature. The lateral retroperitoneum (Zone 2) encompasses the proximal genitourinary system and its vasculature. The pelvic retroperitoneum (Zone 3) contains the iliac arteries, veins, and tributaries of veins. Ideally, proximal (and when applicable, distal) control needs to be achieved before exploring any retroperitoneal hematoma. Retroperitoneal hematomas in any of the three zones require exploration for all penetrating injuries. For retroperitoneal hematomas in Zone 1, mandatory exploration is required irrespective of a penetrating or blunt mechanism. For Zone 2 hematomas resulting from blunt trauma, only pulsatile or expanding hematomas should undergo exploration. Gross extravasation of urine also necessitates exploration. Zone 3 (pelvic retroperitoneum) hematomas should be explored only for penetrating injuries. We found retroperitoneal injuries in nine cases (18.8%) at surgery equally distributed among the three zones.
“Damage-control” strategy, popularized by Rotondo et al., is a staged celiotomy strategy that was initially made operational by Mattox and Feliciano and was labeled as the “Bogota bag” approach [Figure 4]. Mattox and Feliciano popularized the technique in the United States. A staged celiotomy (“damage-control” laparotomy) might be necessary if the patient becomes acidotic, hypothermic, coagulopathic, or hemodynamically compromised. Trauma surgeons have evolved surgical techniques and protocols for managing increasingly severe thoracic, abdominal, extremity, and peripheral vascular injuries according to principles of damage control. Damage control laparotomy is usually performed in high-grade liver and major vascular injuries. The final definitive abdominal closure can be done by secondary suturing once the critical period of increased intra-abdominal pressure is over [Figure 5]. We performed damage control surgery in four (8.3%) cases, out of which two patients succumbed. One patient had aortic bifurcation laceration with IVC rupture and was near completely exsanguinated at presentation, and the other patient had IVC rupture with shattered left kidney with hemorrhagic shock.
|Figure 4: Laparostomy in a case of gunshot wound abdomen. Often at the end of the surgery, the abdominal cavity closure is not possible. A transparent polyethylene covers allow for rapid closure that permits easy postoperative status of the peritoneal cavity “Bogota Bag”|
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|Figure 5: Secondary closure. Formal secondary suturing of the abdomen can be done once the patient has passed the critical stage of increased intra-abdominal pressure|
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| Conclusion|| |
Well-established management protocols for effective management of PTA are laid out. They include urgent transportation to a well-equipped trauma center after first aid by trained staff in golden hours, early recognition of the injuries, early surgical intervention, excellent knowledge of the anatomy, and good surgical judgment. Well-equipped trauma center must have trained trauma team, portable X-ray machine, ultrasound machine, and CT scan with dedicated blood bank. Our study reinforces these management strategies and depicted the worst outcome with hemorrhagic shock. Our study also points to the good outcome by primary repair of small intestine injuries with minimal soiling. Patients who are hemodynamically stable without signs of peritonitis and negative FAST can be managed with nonoperative treatment with close observation and low threshold for surgical exploration in case of deterioration of the clinical condition.
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Conflicts of interest
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| References|| |
Aprahamian C, Thompson BM, Towne JB, Darin JC. The effect of a paramedic system on mortality of major open intra-abdominal vascular trauma. J Trauma 1983;23:687-90.
Demetriades D, Chan L, Cornwell E, Belzberg H, Berne TV, Asensio J, et al
. Paramedic vs. private transportation of trauma patients. Effect on outcome. Arch Surg 1996;131:133-8.
Pepe PE, Wyatt CH, Bickell WH, Bailey ML, Mattox KL. The relationship between total prehospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med 1987;16:293-7.
Dente CJ, Shaz BH, Nicholas JM, Harris RS, Wyrzykowski AD, Patel S, et al
. Improvements in early mortality and coagulopathy are sustained better in patients with blunt trauma after institution of amassive transfusion protocol in a civilian level I trauma center. J Trauma 2009;66:1616-24.
Adams DB. Abdominal gunshot wounds in warfare: A historical review. Mil Med 1983;148:15-20.
Shaftan GW. Indications for operation in abdominal trauma. Am J Surg 1960;99:657-64.
Shaftan GW. Selective conservatism in penetrating abdominal trauma. J Trauma 1969;9:1026-8.
Nance FC, Cohn I Jr. Surgical judgment in the management of stab wounds of the abdomen: A retrospective and prospective analysis based on a study of 600 stabbed patients. Ann Surg 1969;170:569-80.
Păun S, Beuran M, Negoi I, Runcanu A, Gaspar B. Trauma – epidemiology: Where are we today? Chirurgia (Bucur) 2011;106:439-43.
Kristensen JK, Buemann B, Kuehl E. Ultrasonic scanning in the diagnosis of splenic haematomas. Acta Chirurgica Scandinavica 1971;137:653-7.
Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis TP, Wang D, Champion HR. A prospective study of surgeon-performed ultrasound as the primary adjuvant modality for injured patient assessment. J Trauma. 1995;39:492-500.
Ollerton JE, Sugrue M, Balogh Z, D'Amours SK, Giles A, Wyllie P et al.
Prospective study to evaluate the infl uence of FAST on trauma patient management. J Trauma 2006;60:785-91.
Pryor JP, Reilly PM, Dabrowski GP, Grossman MD, Schwab CW. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 2004;43:344-53.
Feliciano DV, Rozycki GS. The management of penetrating abdominal trauma. Adv Surg 1995;28:1-39.
Hauser CJ, Huprich JE, Bosco P, Gibbons L, Mansour AY, Weiss AR. Triple-contrast computed tomography in the evaluation of penetrating posterior abdominal injuries. Arch Surg 1987;122:1112-5.
16 Ivatury RR, Simon RJ, Stahl WM. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma 1993;34:822-7.
Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D, et al
. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: Results of a prospective study. Arch Surg 2006;141:468-73.
Arikan S, Kocakusak A, Yucel AF, Adas G. A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration. J Trauma 2005;58:526-32.
Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan JG. Packing for control of hepatic hemorrhage. J Trauma 1986;26:738-43.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]