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Reparative Surgery (Secondary Surgery) in the Korean Campaign

Medical Science Publication No. 4, Volume 1

REPARATIVE SURGERY (SECONDARY SURGERY) IN THE KOREAN CAMPAIGN*

COLONEL FRANK E. HAGMAN, MC

The management of battle casualties during the Korean conflict, as in World War II, was in phases and conformed, in general, with military echelons and geographic deployment of military forces. This discussion will be limited almost entirely to certain aspects of reparative surgery which pertained to the Korean conflict.

The place reparative surgery had in combat may become clear from a brief examination of the four main phases in managing casualties. This concept was developed in World War II and used successfully in the recent conflict.

1. Medical Aid Measures. These measures were the first phase of management. They were administered within division areas and directed principally toward providing the most competent and urgent care in preparation for the second phase.

2. Initial Wound Surgery. This phase was performed usually in forward surgical hospitals. Initial wound surgery provided the first orderly and definitive surgical treatment of wounds. Under adverse combat conditions initial surgery necessarily was limited in scope.

3. Reparative Surgery. This phase, usually performed in Japan, continued surgical care to completion, beginning where initial surgery left off.

4. Reconstructive Surgery. This phase usually was accomplished in the Zone of Interior. It was the final stage of management for casualties with injuries of such magnitude as to preclude return to duty within the time limit set by the Far East Command.

During the Korean campaign reparative surgery was carried out largely in hospitals in Japan and as in World War II (1) had these objectives:

    1. To shorten the period of wound healing.

    2. To prevent and eradicate wound infection.

    3. To restore function.


*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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    4. To return patients to duty.

    5. As rapidly and safely as possible, to evacuate patients to the Zone of Interior when restoration to duty could not be expected within a reasonable time.

For the purpose of providing the best available care during the reparative phase of surgery, specialized treatment services in hospitals in Japan were organized for casualties inflicted with neurosurgical, thoracic, eye and cold injuries. In addition, efficient centers were provided for treatment of infectious hepatitis and for patients in the convalescence stage following injury or illness who required a period of reconditioning before return to duty.

The support given by personnel and hospitals in Japan to the management of battle casualties stemming from the Korean campaign was supremely and vitally important. On many occasions, because of the tactical situation in Korea, the first definitive surgical care was given in Japan. Moreover, the hospitals in Japan gave magnificient support to casualties with complications either overlooked in forward hospitals or developing inevitably during the patient's course.

Delayed Closure of Wounds

In the Korean campaign primary suture of war wounds in general was neither advocated nor practiced. Based upon experience of World War II (2), wounds were left open after initial surgery. Cranial, cerebral and maxillofacial wounds were exceptions to the policy as also were wounds associated with open injuries of the chest, with abdominal evisceration and with major joints. It soon became apparent that primary suture was unwise for the vast majority of casualties. Despite previous experience, primary suture was performed occasionally. Complications resulting from such practice occurred more often than necessary and were further convincing evidence against primary suture.

Delayed suture of war wounds, therefore, was necessary for most battle casualties subjected to initial surgery in Korea. Delayed closure of wounds constituted a large part of the reparative phase of surgery in Japan. It became a routine procedure, not very stimulating to surgeons interested in more exotic operations. Still it was of great importance to prevent undue cicatrization and production of granulation, obliterating anatomical layers; to prevent the hazards of cross-contamination from bacteria indigenous to the hospital and frequently resistant to available antibiotic and chemotherapeutic agents; and to hasten wound healing and lessen deformity and disability (2). Successful delayed closure in large measure depended


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upon the interest of the surgeon (3) and painstaking attention to many details, among which were-

    1. Period of nontransportability, during which casualties were not sent elsewhere. Immobilization of the region, surgically repaired, was frequently of prime importance.

    2. Thorough débridement prior to closure. Well débrided wounds could be repaired early.

    3. Repairing wounds within 4 to 6 days when possible, using appearance of wound rather than length of time as the governing factor.

    4. Proper preparation of wounds not ready for repair.

    5. Strict avoidance of tension for approximation of tissues.

    6. Adequate drainage, preferably through a small separate stab wound.

    7. Gentleness in handling tissues.

    8. Fine suture material.

    9. Culture and sensitivity studies of bacterial flora when failure occurred.

Secondary Hemmorhage

During the Korean campaign war wounds were often complicated by secondary hemorrhage (4) occurring on the average of 15 days after inception. Although hemorrhage was sometimes venous in origin, usually it ensued after arterial injury, more often associated with rupture of traumatic aneurysm than arteriovenous fistula and more apt to occur in infected than relatively clean wounds. Bleeding occurred unheralded, was alarming and even exsanguinating. Vascular injuries were overlooked at times and became apparent only when symptoms and signs pointed to the presence of traumatic aneurysm, arteriovenous fistula or when tempestuous hemorrhage suddenly supervened. Aneurysms and arteriovenous fistulae were managed conservatively when major vessels were involved and no serious or impending complications became apparent. It was the policy in the Far East Command to return such patients to the Zone of Interior. Operations were performed for indications such as the following:

    1. Manifest internal or external hemorrhage.

    2. Sudden increase in swelling or size of a lesion.

    3. Sudden increase in pain when probably associated with vascular injury.

    4. Imminent rupture of pulsating mass.

    5. Increased swelling of extremity associated with a wound, with impaired circulation and probably not associated with phlebitis per se.

Surgical principles considered of importance were-

    1. Adequate blood volume replacement.

    2. Tourniquet control when possible.


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    3. Long properly placed incision.

    4. Proximal and, when possible, distal control of artery before surgically attacking injured area.

    5. Repair of injured artery when large and important, by suture of defect in its wall, by end-to-end anastomosis or by grafts if necessary (usually vein such as great saphenous).

Neurosurgical Casualties

The management of neurosurgical casualties during the early months of the conflict was a distressing problem, replete with difficulties. These difficulties stemmed from lack of sufficient neurosurgically trained personnel, inability to hold neurosurgical casualties in Korea, pressure of large numbers of other types of casualties, relative inexperience of general surgeons and the uncertainties pertaining to the Korean conflict. During the first months of the campaign, initial craniocerebral surgery was attempted in Korea and Japan by general surgeons. The incidence of complications such as acute and subacute cerebritis and frank brain abcess was reported to be 42 percent (5).

While a neurosurgical service was established in an Army Hospital in Japan soon after hostilities began, it was not until mid September 1950 that this service was headed by a board-certified neurosurgeon. Eventually Army neurosurgical casualties were sent to this service which was kept inordinately busy treating complications. It was not possible until February 1951 to place an Army neurosurgical team in Korea composed of partially neurosurgically trained medical officers under the supervision of the sole board-certified Army neurosurgeon assigned to the Far East Command. The reported incidence of craniocerebral complications gradually dropped to about 4 percent (5). In the meantime (and subsequently) a number of neurosurgical casualties were successfully treated by neurosurgeons assigned to U. S. Navy hospitals and hospital ships, including the Danish hospital ship "Jutlandia."

At least three experienced Army neurosurgeons could have been very usefully employed from the onset of the military effort. Should another conflict occur without warning, cognizance should be taken of this unfortunate experience of insufficient professional personnel for the management of neurosurgical casualties. It seems apparent that the military establishment should have within the regular corps or in reserve, neurosurgeons who could be depended upon to extend adequate support to the Armed Services much more quickly than was the case in Korea.

The volume of the reparative phase of craniocerebral surgery was reduced greatly by improvement of initial surgery. Some of the factors during initial surgery leading to improvement were-


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    1. Débridement of all layers of the scalp.

    2. Excision, en bloc, of involved bone.

    3. Débridement of dura.

    4. Resection of all necrotic brain tissue.

    5. Removal of all indriven bone fragments.

    6. Closure of dura, by facial grafts if necessary.

    7. Removal of metallic foreign bodies when feasible (including opposite side from missile entrance when close to cortex and associated with subdural hematoma).

Penetrating wounds of the spinal column and cord required débridement as completely as soft tissue wounds. Frequently wound care included laminectomy, removal of bone spicules, evacuation of hematoma and excision of devitalized tissue.

Prior to establishing neurosurgical teams in Korea much of this was done in Japan. Patients with paraplegia or quadriplegia were managed with infinite attention to details. Decubitus ulcer was extremely rare while these patients were overseas. These results were obtained by tireless, enthusiastic and sympathetic doctors, nurses and corpsmen. Patients were managed by periodic changes of position, employing the litter turning method or Stryker frame; by excellent nursing attention; by overcoming and preventing anemia; by maintaining and improving nutrition; and by employing catheter rather than suprapubic bladder drainage. They were transported to the Zone of Interior in pressurized cabin planes, on Stryker frames and under the supervision of trained personnel.

Thoracic Injuries

In the early days of the conflict patients with complicated thoracic injuries often were sent to the Zone of Interior because of insufficient hospital beds and personnel, circumstances beyond anyone's control at the time.. Two Army thoracic surgical services were established and eventually were able to carry out reparative surgery. One service (6), for example, from the beginning of hostilities until November 1952 (16 months) gave the following support to battle casualties with visceral chest injuries:

Total patients treated

2,577

Penetrating wounds

1,855-72 percent.

Perforating wounds

670-26 percent.

Crushing injuries

52-2 percent.

Patients with hemothorax

1,598

Remaining bacteriologically sterile

1,182-74 percent.

Infected

416-26 percent.

Chest clear after treatment

1,262-79 percent.

Returned to duty

68 percent.

Evacuation to ZI with other injuries

32 percent.


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During this interval 230 decortications were done on the service with the following results:

Infected

76 percent.

Noninfected

24 percent.

Good results-duty

91 percent.

Fair results-limited duty

4 percent.

Poor results-evacuated

5 percent.

The optimum time for decortication was found to be between 3 and 5 weeks. If attempted too early, bleeding, edema and difficulty in locating foreign bodies were noted. Ninty-two percent of patients requiring decortication had had closed intercostal tube drainage for hemothorax prior to being sent to this thoracic surgical service. While there were no doubt many other contributing factors, this sort of experience was used to intensify efforts in forward hospitals to treat hemopneumothorax by needle and syringe aspiration rather than by inserting intercostal tubes for drainage of hemothorax.

During this period foreign bodies were removed from the chest of 280 patients. These were classified as follows:

Shell fragments removed, 1-9 cm., mostly irregular

85 percent.

Bullets, various caliber

15 percent.

Mediastinal foreign bodies

77.

Pericarditis with effusion

34.

With abcesses

18.

Of heart muscle

14.

Operation for foreign bodies was employed for missiles 1.5 cm. in diameter or greater, when they were in a dangerous location or when they demonstrated persistent or developing reactions about them. Operation was delayed for 2 to 3 weeks to permit subsidence of local reaction about foreign bodies to lessen bleeding, facilitate locating and removing and to get patients in best possible condition.

Patients with thoraco-abdominal wounds were usually evacuated to the ZI because of complications associated with abdominal wounds. Chest injuries associated with neurosurgical injuries (271) were problems to manage and in paraplegics were aspirated and drained with difficulty because of position. Patients with associated orthopedic injuries (602) in the majority of instances required evacuation to the Zone of Interior.

It is of more than passing interest that the overall mortality for patients on this service during the period of this report was 0.5 percent and the surgical mortality was zero.

Maxillofacial Wounds

Reparative surgery of maxillofacial wounds was done usually by teams comprised of a general surgeon, interested in and familiar with


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the head and neck, a dental surgeon experienced in this field, an experienced anesthesiologist or anesthetist capable of giving nasotracheal, orotracheal or transbronchial anesthesia, and competent nurses and corpsmen (7). Nasogastric intubation was employed for feeding patients when swallowing was difficult and for patients troubled with vomiting.

Wounds extending into the month frequently disrupted, especially when buccal mucosa was not sutured initially and when good mouth hygiene was neglected. Gross infection and necrosis were treated by irrigation, antibiotics, removal of foreign bodies and loose bone spicules and loose and broken teeth.

Fine absorbable everting mattress sutures were employed within the mouth to close the buccal cavity and cover bone. Dependent drainage was provided. Covering was furnished for avulsed jaws, lips and mucosa. Fractures were treated by fixation employing intraoral wiring or extra-oral fixation. Postoperative irrigations were employed every 2 hours or oftener and after intake of food. Tracheotomy was done, if not done previously, for extensive injuries of the tongue, larynx and neck, or when hemorrhage, infection or edema threatened embarrassment of the air passages. Injuries of the parotid duct were repaired over a ureteral catheter employing 5-0 silk sutures. Mucoperiosteal flaps were provided for injuries involving the hard palate.

Patients requiring extensive reconstructive maxillofacial surgery were returned to the Zone of Interior. Important principles of rnaxillofacial repair included-

    1. Frequent saline irrigations.

    2. Large doses of antibiotics.

    3. Early débridement.

    4. Conservation of skin and bone.

    5. Removal of loose teeth and bone spicules.

    6. Early closure of mucous membrane.

    7. Dependent drainage.

    8. Fixation of fractures.

    9. Postoperative irrigations.

    10. Tracheotomy as indicated.

    11. Teamwork.

Abdominal Wounds

Experience in Korea did not change concepts of managing wounds of the large intestines as promulgated during World War II. Most surgeons practiced exteriorization of large bowel injuries through a


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separate muscle-splitting incision. Occasionally an individual surgeon failed to follow this general practice, closed colonic wounds primarily and dropped the colon back into the abdomen. In some patients nothing untoward happened. However, too many patients so treated developed abscess, fecal fistula and increased disability to warrant primary closure despite liberal use of whole blood, antibiotics, etc.

The difficulty with exteriorization stemmed, first, from employing laparotomy wounds rather than separate muscle-splitting incisions, and second, from inadequate mobilization of the bowel at the time of exteriorization (or defunctioning colostomy). The former increased severe infection while the latter resulted in retraction of the colon in whole or in part back into the abdomen. In either event the resulting difficulties provided clinical material for surgeons in Japan, complications preventable in whole or in part at the time of initial surgery. Furthermore, rectal injuries which had escaped recognition initially presented problems such as fecal fistula, abscess and retroperitoneal cellulitis. Aside from revising and instituting colostomies, surgeons were able to close many colostomies and return patients to duty within the theater.

Efforts were directed towards repairing fistulae of the small bowel early to prevent further depletion of nutrition, water and electrolyte balance and when closure was impracticable to short-circuit around them to accomplish the same purpose. The many and various complications involving wounds of the abdomen were treated in accordance with sound surgical principles supported by all available adjuvants.

Extremities

The basic concepts derived from World War II for managing injuries of the extremities were employed. These included an adequate period of nontransportability for the casualty to provide balanced suspension and traction for reduction and alignment of fractures until union occurred, early closure of wounds, additional débridement as necessary, careful attention to nutritional and blood deficiencies and administration of appropriate antibiotics.

Evacuation of patients to the Zone of Interior with open fractures of major bones had to be done early during periods of acute shortage of facilities in Japan (8). When patients could be returned within 2 weeks after wounding this practice was reported by orthopedic surgeons in the Zone of Interior, who subsequently received and treated them, to have certain advantages:

    1. Less beds were required overseas.


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    2. Patients were received early enough for definitive treatment and required no further movement until completely rehabilitated.

    3. Slight delay did not materially increase wound infection, impair the results of wound closure, decrease function or increase disability.

    4. But there must have been absence of complications and contraindications, and transportation must have been completed within the 2-week period.

Interamedullary fixation (9) of long bones was usually reserved for closed fractures and therefore was not employed extensively in battle casualties. However, occasionally the method was used when débridement had been satisfactory, permitting early closure of soft tissues, and it appeared reasonably certain that the patient could be sent to duty within the theater.

Convalescence Hospitals

It is abundantly clear that the foregoing discussion has dealt with only a few highlights of reparative surgery. Before concluding, a few remarks concerning hospitals for convalescence and rehabilitation should be made. Separate organizations were provided without elaborate treatment machinery. These units carried out dynamic, efficient, complete, and uniform programs to fill the devitalizing hiatus which existed after patients required no further definitive care but still were not fit for return to duty.

Convalescence hospitals in Japan served with great distinction and furnished brilliant backing for other hospitals during the final phase of medical care. The approach to patients was positive (10), aimed at rapid restoration of function and resumption of normal physical activities. Patients soon began to look and act like soldiers.

Many ambulatory neuropsychiatric patients were sent to convalescence hospitals direct from Korea. Under the supervision and care of psychiatrists they participated in the reconditioning program.

All patients were placed in one of four classes in accordance with their physical condition after evaluation by medical officers in attendance. As rapidly as possible patients were placed into the next more active class and finally discharged to duty.

Patients were organized into military units, lived in barracks, complied with demands of military discipline and alternated physical activities with classroom work. At all times the environment of convalescence hospitals was such that patients were encouraged to shed spurious gains of chronic invalidism for resumption of adult obligations of normal human beings.

References

1. Technical Bulletin Med. 147. Department of the Army, 22 June 1951.

2. Churchill, E. D.: Management of Wounds. Symposium on Treatment of Trauma in the Armed Forces XI, 1-5, March 1952. Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.

3. Fisher, Daniel: Secondary Closure of Wounds. The Surgeons Circular Letter. Med. Sec. GHQ FEC SCAP and UN Vol. VI, No. 9, September 1951.

4. Russell, J. P.: Symposium on Military Medicine in the FEC. Supplementary Issue, The Surgeons Circular Letter, page 66, September 1951.

5. Melrosky, A. M.: Annual Report on the Management of Neurosurgical Casualties in the FEC. The Surgeon FEC, 1951.

6. Valle, A. R.: Analysis of Chest Casualties Treated in a General Hospital. Med. Bulletin US Army Far East, Vol. 1, No. 4: 60, March 1953.

7. Rush, J. T., and Quarantillo, E. P.: Maxillofacial Injuries. Annals of Surgery 135: 205-220, 1952.

8. Bollibaugh, O. B.: Symposium on Military Medicine in the FEC. Surgeons Circular Letter (supplementary issue), page 66, September 1951.

9. Kirkpatrick, C. L., Jefferies, V. H., Neatuska, W. H., and Radke, R. A.: Operation of Tokyo Army Hospital. Med. Bulletin US Army FEC. Vol. 1, No. 9, 166-167, August 1953.

10. Cooch, J. W.: Experience in the Operation of a Convalescence Hospital. Surgeons Circular Letter. Med. Sec. GHQ FEC, SCAP and UN Vol. VI, No. 11, 232-233, November 1951.