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Chapter 29

Contents

CHAPTER XXIX  

Special Types of Abdominal Injury  

Gordon F. Madding, M. D., and Knowles B. Lawrence, M. D.  

VISCERAL INJURIES WITHOUT PENETRATION OF THE PERITONEAL LAYER OF THE ABDOMINAL WALL  

In 12 of the 3,154 abdominal injuries observed by the 2d Auxiliary Surgical Group during 1944 and 1945, injuries of abdominal viscera occurred without penetration of the abdominal wall by the wounding missile (table 96).  

In 10 of the 12 cases the missile, while it caused a through-and-through wound of the abdominal parietes, did not injure the peritoneum. In the 2 other cases, the foreign body was retained within the abdominal wall. The velocities of the missiles causing the through-and-through wounds were apparently greater than those of the missiles retained within the abdominal wall. It may be assumed that the additional imparted energy produced an explosive effect in the abdominal wall, and that this effect was imparted, in turn, to the intra-abdominal structures.  

The fact that viscera containing gas and liquid (that is, hollow viscera) were injured in 9 of the 12 cases suggests that this type of viscus may be peculiarly prone to injury from indirect trauma because of the transmission of the force of the missile by the visceral contents. The fact that in one case (table 96, case 3) the cecum and ascending colon were split open along the anterior longitudinal band seems to support this theory.  

In the single fatal case in this group (table 96, case 8) the patient sustained a severe wound of the left chest. The missile lacerated the pleural surface of the left dome of the diaphragm, with apparent indentation of the stomach wall and production of a subserosal hematoma in that area. Pulmonary damage was extensive, and the intra-abdominal injury seems to have played no significant part in the fatality, which was the result of shock and pulmonary edema.  

The experience of the group surgeons with injuries of the abdominal wall which did not involve the peritoneal layer clearly indicates that it would have been an error to assume that there was no intra-abdominal visceral injury merely because the missile did not enter the peritoneal cavity. Whenever there was clinical evidence of intraperitoneal involvement, exploration was regarded as mandatory. The visceral injuries thus found in this series are proof of the wisdom of that policy.  


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TABLE 96.-Essential data in 12 injuries of intraperitoneal viscera without penetration of peritoneal layer of abdominal wall


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VISCERAL INJURIES CAUSED BY BLUNT TRAUMA AND BLAST  

Perforation or rupture of an intra-abdominal viscus, which is always a possibility in any instance of blunt trauma or blast, occurred in 14 of the 3,154 abdominal injuries in this series (0.44 percent) in the absence of peritoneal penetration (table 97). These cases are exclusive of injuries to the bladder, urethra, and other urogenital structures associated with fractures of the pelvis. The small intestine, the spleen, the colon, the mesentery, and the kidney were most frequently injured, alone or in combination.  

Nine of the fourteen injuries resulted from vehicular accidents and three from blast from a nearby explosion of an artillery shell. Occasionally a subcutaneous hemorrhage indicated the area of greatest trauma, but in none of these injuries was there a skin wound. The diagnosis of possible intra­abdominal injury was made in 13 of the 14 cases by the history of injury and the physical findings. Tenderness was usually present, and peristalsis was constantly absent. In the remaining case (table 97, case 14) an extensive thoracic injury overshadowed the abdominal injury, which was not suspected until autopsy.  

The case fatality rate in this group (2 deaths in 14 cases) is considerably lower than the rates of 44 and 55 percent reported in the literature for this type of injury. The good results are attributable to early and vigorous therapy for shock, followed by prompt surgical intervention. The series may be small, but in the majority of cases the lesions were such that death would undoubtedly have occurred in the absence of surgical intervention.  

PENETRATING (PERFORATING) WOUNDS OF THE ABDOMINAL WALL WITHOUT VISCERAL INJURIES  

The peritoneal cavity was penetrated in 41 of the 3,154 abdominal wounds in this series (1.3 percent) without significant damage to any of the intraperitoneal viscera.1 The wounds were perforating in 11 of the 40 recorded cases and penetrating in the other 29. The wounding agent was listed as a high­explosive shell fragment in 33 cases and as gunshot in the other 8.  

In 24 of the 41 cases, the wounds were thoracoabdominal. This proportion (58.5 percent) differs materially from the 26.2 percent of thoracoabdominal wounds in the entire series of 3,154 abdominal injuries, though the figures are too small to be of real significance. The right diaphragm was wounded 13 times and the left 11 times. In 23 of the 24 cases in this group, the missile entered the peritoneal cavity from the thorax. In 7 cases, there was a double perforation of the diaphragm, the missile either lodging in the lung or passing out through the chest wall. In 2 of the 11 single perforating wounds, the injury was produced by sharp rib fragments. In the 5 other cases in which  

1Three similar cases in which only the omentum was injured are not included in these 41 cases. In 2 of the 3, small rents in the omentum were repaired by suture. In the third case, a segment of omentum had herniated through a perforation in the diaphragm and become gangrenous. Resection was followed by an uneventful recovery.


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TABLE 97.-Essential data in 14 intra-abdominal injuries caused by blunt trauma and external blast

the missile entered the abdomen from the thorax, it lodged in the diaphragm and caused only a small opening in the peritoneum.  

In none of the 17 abdominal wounds had the missile passed freely across or through the general peritoneal cavity in a major diameter. In every instance, the peritoneal wound had been caused by missiles which had either perforated the cavity across small angles, lacerated the peritoneum in burrowing through extraperitoneal tissues, or so exhausted their momentum as to fall harmlessly into the peritoneal cavity.  

Hemoperitoneum in varying degrees, all from extraperitoneal sources, was present in most of the 41 cases. It was this blood, sometimes more than a liter, which produced the clinical symptoms and signs of an intraperitoneal lesion.  

The surgical approach in each instance was determined by the type of wound. In 20 of the 24 thoracoabdominal wounds, exploration was carried out through the chest and diaphragm. In two other cases, it was carried out through separate incisions in the chest and abdomen. The remaining operations were performed through abdominal incisions. The wound of the diaphragm was sutured in all thoracoabdominal wounds.  

There were 2 deaths in the 41 cases. One patient, who had sustained an evisceration of 18 inches of ileum through a wound of the abdominal wall, died unexpectedly, 3 days after operation, of massive pulmonary embolism, the origin of which was not stated. In the other fatal case, a severe retroperitoneal injury with severance of the left common iliac vessels, death occurred 10 days after operation, from peritonitis, retroperitoneal cellulitis, and pneumonia.  

The most important observation made in this group of cases is that in not a single instance did a missile pass harmlessly across the general peritoneal cavity in a major diameter. Since the whole series represents a very large number of cases (3,154) and since the policy was to explore every injury in which there was evidence of or suspicion of peritoneal penetration, it would seem that perforating wounds of the peritoneal cavity in which there is no injury of the intraperitoneal structures must be extremely uncommon. It is true that because of the tendency of certain wounds of the gastrointestinal tract to seal over, clinical recovery may occasionally ensue in such cases, without surgery and therefore without diagnosis, but because of the excellent surgical service and facilities provided in forward hospitals in World War II, the risks involved in the nonsurgical management of this type of wound would not have been justified.

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