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Chapter 27

Contents

CHAPTER XXVII  

Wounds of the Great Vessels of the Abdomen (75 Casualties)  

Hugh F. Swingle, M. D., and Dominic S. Condie, M. D.  

There were 75 wounds of one or more of the major vessels of the abdomen included in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical Group during 1944 and 1945 (table 89).1 These injuries (table 90) consisted of: 

1. Injuries to the major veins, including the vena cava; the common, internal, and external iliac veins; and the portal vein (53 cases).

2. Injuries to major arteries, including the common, internal, and external iliac arteries (13 cases).  

3. Injuries to some combination of these arteries and veins (9 cases).  

TABLE 89.- Essential data in 75 wounds of major vessels of abdomen

Type of injury

Cases

Frequency

Deaths

Case fatality rate

In 3,154 abdominal injuries

In 75 vascular injuries

 

 

Percent

Percent

 

 

Vascular only

8

0.25

10.7

5

62.5

Vascular and visceral

67

2.13

89.3

50

74.6


Total

75

2.38

100.0

55

73.3


Of the 75 casualties, 55 (73.3 percent) died, and no soldier with an injury to the abdominal aorta survived long enough to undergo surgery in a field hospital.

INJURIES TO THE MAJOR VEINS

Injuries of the major veins of the abdomen (table 90) occurred alone in 45 cases, in combination with injuries of the blood supply of various viscera in 8 cases, and in combination with injuries of the major arteries of the abdomen in 9 cases.  

1Injuries to the blood supply of special viscera, such as the colon, spleen, and kidney, are discussed under the heading of the viscus involved and are excluded from this discussion unless they complicated wounds of the major blood vessels of the abdomen. As a matter of convenience, combined injuries of the arteries and veins are discussed under the heading of arterial injuries. Because of the wide distribution of injuries and operations and the small numbers in each category, it is necessary to describe many cases in all categories individually.  


318 

TABLE 90.-Influence of type of injury on case fatality rates of 75 wounds of major vessels of abdomen

Injury

Cases

Deaths

Case fatality rate

Veins only

45

33

73.3

    

Single vein

38

27

71.1

    

Two or more veins

7

6

85.7

Vein and visceral blood supply

8

8

100.0

Arteries only

13

8

61.5

Artery and vein

9

6

66.7


Total

75

55

73.3


Vena caval injuries.-The vena cava was injured 33 times (table 91), more frequently than any other single vessel. In the 22 cases in which the injury was univisceral, there were 17 deaths. Nine followed ligation, which was employed in twelve of the univisceral injuries, and four followed suture, which was employed in six cases in the same category. In one fatal case, the vena cava was clamped tangentially, as a temporary measure, and in the three other univisceral fatalities hemorrhage proved uncontrollable.  

The were 10 deaths in the 11 injuries associated with injuries of other major abdominal vessels or of the visceral blood supply.  

TABLE 91.-Essential data in 33 injuries of vena cava

Type of injury and therapy

Cases

Deaths

Case fatality rate

Vena cava:

 

 

 

    

Without other injuries

22

17

77.3

    

With other vascular injuries

4

3

75.0

    

With visceral and other vascular injuries

7

7

100.0


Total

33

27

81.8

Therapy (all vena caval injuries):

 

 

 

    

Ligation

16

13

81.2

    

Suture

8

5

62.5

    

Tangential clamping

1

1

100.0

Spontaneous thrombosis

1

1

100.0

Uncontrollable hemorrhage

7

7

100.0


 


319  

Univisceral injuries of other major veins.-In the 16 univisceral vascular injuries in which veins other than the vena cava were implicated, the distribution of cases, procedures, and deaths was as follows:  

Six injuries of the common iliac vein were treated by ligation in five cases and by packing in one case, with four deaths.  

Five injuries of the external iliac vein were treated by ligation, with two deaths.  

Two injuries of the internal iliac vein were treated by ligation, with one death. Another, similar injury was treated by packing and ended fatally. In the last-mentioned case, the injury was described as involving the "pelvic" vein, but the record left no doubt that the vessel injured was the internal iliac vein.  

Two injuries of the portal vein were both fatal. Packing was employed in one case, and in the other hemorrhage was uncontrollable by any measures. 

Multiple venous injuries.-In the 7 cases in which 2 or more of the major veins of the abdomen were injured (table 90), the distribution of the cases, procedures, and (6) deaths was as follows:  

The inferior vena cava and the common iliac vein were involved in three cases. One patient, treated by suture, survived. One died after venous ligation, and in the third case hemorrhage was uncontrollable.  

The inferior vena cava, both common iliac veins, and the right internal iliac vein were injured in one case. Death followed ligation.  

The left common iliac vein and the left internal iliac vein were wounded in one case, and the same veins on the right side were wounded in another. Death followed venous ligation in both.  

The right internal and external iliac veins were wounded in one case, in which death followed ligation.  

Combined injuries of the major abdominal veins and the visceral blood supply.-All eight cases in which venous injuries were combined with injuries of the blood supply of major abdominal viscera ended fatally (table 90):  

The inferior vena cava, the hepatic artery, and the portal vein were wounded in one case, in which death was caused by uncontrollable hemorrhage. 

The inferior vena cava and the hepatic artery were injured in one case. The artery was ligated, and the vena cava underwent spontaneous thrombosis. 

The inferior vena cava and the superior mesenteric artery were injured in one case. The vena cava was ligated and the artery sutured.  

The inferior vena cava and the right gastric artery and vein were injured in one case. The gastric artery and vein were ligated, but the patient died of uncontrollable hemorrhage from the vena cava.  

The inferior vena cava and the right renal pedicle were injured in three cases. Nephrectomy was done in two cases, once combined with suture, and once with ligation, of the vena cava. In the third case, hemorrhage from both sources proved uncontrollable.  

The portal vein and the hepatic artery were injured in one case, in which packing was employed.  


320 

INJURIES TO THE MAJOR ARTERIES

Arterial injuries.-In the 13 cases in which major arteries of the abdomen were injured without complicating injuries of other vessels (table 92), the distribution of cases, procedures, and deaths was as follows:  

Six wounds of the external iliac artery were treated by suture in one case, with survival, and by ligation in five cases, with four deaths.  

Three wounds of the internal iliac artery were treated by ligation, with two deaths.  

Four injuries of the common iliac artery were treated by suture in two cases, with survival in both, and by ligation in two cases, with death in both. 

Combined arterial and venous injuries.-There were 6 deaths in the 9 combined arterial and venous injuries (table 93). In one instance, a clamp was applied to the internal iliac artery and vein and left in situ because the  

TABLE 92.- Essential data in 13 injuries of major abdominal arteries

Injuries and therapy

Cases

Deaths

Case fatality rate

Vessel injured:

 

 

 

    

External iliac

6

4

66.7

    

Internal iliac

3

2

66.7

    

Common iliac

4

2

50.0


Total

13

8

61.5

Therapy:

 

 

 

    

Ligation

10

8

80.0

    

Suture

3

0

0


TABLE 93.-Essential data in 9 combined injuries of major arteries and veins of abdomen

Vessel injured and therapy

Cases

Deaths

Case fatality rate

External iliac artery and vein

2

1

50.0

Internal iliac artery and vein

6

4

66.7

Common iliac artery and vein

1

1

100.0


Total

9

6

66.7

Therapy:

 

 

 

    

Ligation

8

5

62.5

    

Clamp

1

1

100.0


 


321

patient was moribund; he died before a more definitive procedure could be accomplished. Both the vein and the artery were ligated in the other eight cases. Three patients survived, one with a wound of the external iliac artery and vein and two with wounds of the internal iliac artery and vein.  

POSTOPERATIVE VASCULAR INSUFFICIENCY  

Postoperative vascular insufficiency occurred in 9 patients in this series who survived injury and operation long enough to present it. The veins were affected in 4 cases, the arteries in 3, and both arteries and veins in 2, as follows:  

Two patients with injuries of the inferior vena cava presented swelling of the lower extremity. In one instance, the vein had been ligated. The other patient, who later died of massive pulmonary embolism, had undergone suture of the vein. Two other patients with similar injuries presented distention of the veins of the lower extremities. In one instance, the vena cava had been ligated; in the other, it had been sutured, and it was thought that thrombosis had probably occurred subsequently at the site of injury and repair.  

In one injury of the external iliac artery, gangrene followed ligation of the artery and elective ligation of the vein. The leg was demarcating at the midcalf when the patient died on the third day after operation of anuria combined with an overlooked retroperitoneal injury of the cecum. In another injury of the external iliac artery treated by ligation, amputation was necessary at the left midthigh on the seventh day after operation because of gangrene resulting from arterial insufficiency and clostridial myositis.  

In one injury of the common iliac artery, the artery was ligated, and elective ligation of the vein was also done. Amputation was later necessary through the thigh on the affected side, and the patient eventually died of clostridial infection in the stump.  

In one case in which wounds of the left external and internal iliac veins and the left internal iliac artery were treated by ligation, the affected leg became mottled and cold 12 hours after operation. The patient died 40 hours after operation, in shock from severe peritonitis. Amputation of the extremity would probably have been necessary if he had lived.  

In one case in which the left common iliac artery and vein were injured, both vessels were ligated. Gangrene ensued, and amputation of the extremity through the thigh was necessary on the fourth postoperative day.  

Conditions in forward hospitals did not permit intensive efforts at combating postoperative vascular insufficiency in the lower extremities. Environmental temperature control was not feasible. No anticoagulant drugs were available. The only practical prophylactic measure was control of the patient's position, and the optimum posture was usually contraindicated by the presence of severe intraperitoneal injuries. A few sympathectomies were done on patients with injuries of the femoral artery, but this procedure was not employed in any intra-abdominal vascular injury.


322 

FACTORS OF MORTALITY  

Since the frequency of injury to any abdominal viscus is directly proportional to the space which it occupies (p. 92), it would seem that injury to corresponding major arteries and veins would occur with approximately the same frequency because the vessels are of approximately the same size. In this series of 75 injuries of major abdominal blood vessels, this generalization did not hold. Fifty-three injuries involved one or more veins, while only twenty-two involved either arteries alone or arteries and veins. These figures require interpretation. The considerable discrepancy is probably not a disparity of incidence but rather a disparity in lethality. It arises from the fact that fewer patients with arterial injuries reached field hospitals to undergo treatment. This reasoning is supported by the fact that this series, although it includes 33 lesions of the vena cava, includes no lesion of the abdominal aorta, since no patient with an injury of that vessel survived to undergo surgery. Even when the damage to the veins was severe, many patients were brought to the hospital alive, apparently because a point was reached in the hemorrhagic process at which the intra-abdominal tension was sufficiently high, and the venous pressure had become sufficiently low, to prevent complete exsanguination and death. This physiologic process apparently occurred much less often in arterial injuries, with the result that fewer patients in this category were received in forward hospitals.  

The case fatality rate for all arterial injuries was 63.6 percent (14 of 22 cases), as compared to a rate of 75.8 percent (47 of 62 cases) for all injuries of the veins. The lower case fatality rate in arterial injuries must be attributed to unusual circumstances which permitted the patients to reach field hospitals alive. No precise data are available, but it seems reasonable to assume that in these cases the injuries were slight to minimal, the blood loss before operation was not excessive, and bleeding could be controlled promptly after the abdomen was opened.  

Only 6 of the 33 patients with injuries of the vena cava (table 91) survived long enough after operation to be evacuated from the field hospital. Three had been treated by suture and three by ligation, the procedure in each instance being performed below the renal veins. No patient survived when the injury was above the renal vessels.  

The case fatality rate in injuries of the great vessels apparently rested on much the same basis as injuries of other viscera. Half of the deaths in the 54 fatalities in which the cause of death could be determined resulted from shock and hemorrhage. Twelve were attributed to anuria, four to pulmonary embolism, three each to pneumonia and to pulmonary edema, two each to peritonitis and to clostridial myositis, and one to retroperitoneal suppuration.


323

One factor of great importance in the outcome was the stage of shock. In very severe shock, the blood pressure and pulse were not usually obtainable, and in several other cases the blood pressure and pulse were not recorded when the patient was first seen in the field hospital. The classification into degrees of shock was therefore made on the clinical findings. The case fatality rate (table 94) was directly proportional to the degree of shock on the patients' admission. The numbers of cases in some categories are too small to be sig­nificant statistically, but the results are in full accord with clinical impressions  

TABLE 94.-Influence of degree of shock on case fatality rates in 69 wounds of major vessels of abdomen1  

Degree of shock

Cases

Deaths

Case fatality rate

None

4

2

50.0

Mild

2

1

50.0

Moderate

16

10

62.5

Severe

8

6

75.0

Very severe

39

33

84.6


Total

69

52

75.4


1In 6 cases, 3 of which were fatal, the degree of shock was not recorded.  

The case fatality rate in these 75 vascular injuries also depended upon a number of other considerations, including the presence or absence of associated visceral injuries and the number of viscera involved (table 95). There is one discrepancy-that the rate was higher when no abdominal viscera were involved than when one organ was injured. With this exception, there was a gradual rise in the rate as the number of abdominal organs injured increased. When the multiplicity factor for all abdominal injuries (p. 107) is studied in relation to the multiplicity factor in these 75 cases, it becomes clear that the injury to the great vessels was the most important cause of the consistently high case fatality rate in this group of cases.  

Injuries to the great vessels of the abdomen carried the highest case fatality rate of any category of injuries in this series of 3,154 abdominal wounds. No problem so challenged the technical skill of the surgeon as the control of severe intra-abdominal hemorrhage with sufficient rapidity to give the patient a chance of survival.  


324

TABLE 95.-Influence of multiplicity factor on case fatality rates in 67 wounds of major vessels of abdomen1

Organs injured

Cases

Deaths

Case fatality rate

Major vessels only

8

5

62.5

Major vessels and 1 viscus

22

12

54.5

Major vessels and 2 viscera

21

17

81.0

Major vessels and 3 viscera

13

11

84.6

Major vessels and 4 viscera

1

1

100.0

Major vessels and 5 viscera

2

2

100.0


Total

67

48

71.6


1In 8 cases, 7 of which were fatal, no data are available concerning the number of viscera injured.

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