66. Abdomen
From Primary Surgery
The general method for an abdominal injury
The organs in a patient's abdomen can be injured by a stab from a sharp object, or a blow from a blunt one. As Hippocrates knew, the gut can be ruptured, even if there is no visible mark on the abdominal wall. A patient can die from bleeding into his peritoneal cavity, especially from rupture of his spleen or liver, or from a leaking gut. Your main tasks are: (1) to diagnose that a patient has an abdominal injury, (2) to stop it bleeding, (3) to suture his injured small gut. Occasionally, (4) you will need to exteriorize his injured large gut. He has at least a 50% chance of having at least one other severe injury, so you will have to treat that too.
Blunt injuries are particularly difficult because: (1) A patient may give no clear history that he has had an abdominal injury, especially if he is a frightened child. His injury may be so mild that you have to question him carefully, and he may even walk into hospital. (2) His other more obvious injuries, such as a fractured femur, may distract your attention. (3) He may be drunk, or unconscious from a head injury and unable to tell you his symptoms. If you anaesthetize him to treat his other injuries, he cannot complain of increasing abdominal pain. (4) For the first few hours after a blunt injury his abdomen may be deceptively normal. Although a haemoperitoneum usually causes pain, tenderness, guarding, and absent bowel sounds, it ocasionally causes none of these things, especially in children. (5) Distinguishing between muscle pain and peritoneal irritation can be very difficult. (6) Some injuries may not show themselves for several days, especially a subcapsular haematoma of the spleen, or a retroperitoneal injury of the pancreas or duodenum.
For all these reasons, abdominal injuries need particular judgement, care, and skill. So, be vigilant and suspicious. You will need a watchful eye, a light touch, and a sympathetic ear. Don't let a patient go home if there is even a slight possibility that he might have injured his abdomen. If you are in any doubt, observe him carefully and use the special methods described below. They will be particularly useful if he also has a head injury, and may indeed save his life. The decision to operate will be much more difficult if you have already anaesthetized him to reduce a fracture, and he is already on traction or in a cast. If he is going to need a laparotomy, try to do it early.
MURAV ULAL was a sailor who fell on to a crate. In the casualty department no injuries were found and his blood pressure was normal. However, the casualty officer was worried about the possibility of an abdominal injury, because there was an abrasion on his pigastrium, so she admitted him. When the registrar saw him in the ward half an hour later he was severely shocked. Urgent laparotomy revealed a ruptured spleen.
MOHAN (25) had been kicked in the abdomen during a fight. His abdomen was bruised and abraded, but he did not look as if he had been seriously injured . The medical assistant who saw him gave him aspirin and sent him home. Three days later he was admitted with severe peritonitis. A quantity of pus and intestinal contents were removed from his abdomen, but he died soon afterwards.
LESSONS (1) Any abdominal abrasion after a blunt injury should make you suspect an internal injury. (2) A young adult can maintain his blood pressure for some hours after an injury, and it may even rise before it falls catastrophically.
A CLOSED INJURY CAN EXIST WITHOUT ANY EXTERNAL SIGNS
GENERAL METHOD FOR ABDOMINAL INJURIES
This extends Section 51.3 on the care of a severely injured patient. It is mainly concerned with blunt injuries. For penetrating ones goto Section 66.2.
HISTORY Most abdominal injuries are the results of car accidents, but some follow falls from a height, especially in children.
What object struck the patient's abdomen? Where did it strike him? For example, an injury to his spleen is much more
likely after a blow to his left lower chest. How much force was used?
PAIN after an abdominal injury is always important. It is, usually present, but a patient may not complain of it if he has even more painful injuries elsewhere. Where is the pain? What kind of pain is it? Is it getting better or worse? If pain is getting worse after an abdominal injury, it probably means continued bleeding, or a leaking gut. Has the patient got pain at the tips of either of his shoulders? (make sure that this is not caused by an injured shoulder). Shoulder tip pain is caused by irritation of hi diaphragm, usually by blood. It is a particularly useful sign of injury to the liver (right shoulder) or the spleen (left shoulder), especially if tilting the patient's head down makes it worse.
CAUTION ! Almost all patients with abdominal lesions after a blunt injury have persistant pain, and vomit. So these are very important signs. To begin with they may be almost the only ones.
THE EXAMINATION OF AN ABDOMINAL INJURY
I f the patient is bleeding, he is likely to be pale, anxious, and still, with cold extremities. Completely uncover his chest and abdomen and sit beside him.
How is he breathing? Shallow, irregular, or grunting respiration is typical of an abdominal injury.
Look for bruises and abrasions. They will show you where he was hit.
Feel for tenderness. This is less marked with a haemoperitoneum than it is with septic peritonitis. Its position may guide you as to which organ has been injured. increasing tenderness usually requires a laparotomy.
Rebound tendernesss is unreliable and is easily confused with muscle bruising. Pain on coughing and on percussion with your finger tips is much more reliable.
Feel for guarding and rigidity. Guarding progressing to rigidity is a reliable sign of peritonitis. Percuss the patient's flanks for the dullness that may indicate a haemoperitoneum. Test for shifting dullness.
CAUTION ! Even minimal tenderness and guarding are significant.
Listen for bowel sounds for 2 minutes. If you hear them, they mean nothing. When you first examine a patient, his abdomen will probably not have had time to become silent. However, an abdomen which is silent, or becomes silent later, is a useful sign of peritonitis.
Has the patient any signs of fractured ribs (65.1)? If his lower left ribs are fractured, suspect a ruptured spleen. Thoraco-abdominal injuries are common. Cyanosis is a dangerous sign.
Examine him rectally. If the patient is a woman, examine her vaginally while she is lying on her back, then examine her rectally. Look also for blood on your glove. Fullness or tenderness in the recto-vaginal pouch in a woman or the recto-vesical pouch in a man may indicate a haemoperitoneum. Look for wounds of the perineum or buttocks at the same time.
CAUTION ! The rectum is completely out of sight at laparotomy. To begin with its injuries may cause no symptoms. If necessary, pass a sigmoidoscope.
Aspirate the patient's stomach and empty his bladder. If you aspirate blood, his stomach may have been injured. Leave the nasogastric tube down. You will want it later when he goes to the theatre.
HAS HE LOST MORE BLOOD THAN CAN BE ACCOUNTED FOR BY HIS KNOWN INJURIES? This is good evidence for abdominal (or thoracic) bleeding. Assess it by the methods in Section 53.2.
SHOULD YOU ADMIT THE PATIENT?
Admit and observe him if you think he might have an abdominal injury. Half the patients you admit will not have one, but you may save the lives of the other half. If his nose is cold (53.2), be sure to admit him.
SPECIAL METHODS FOR ABDOMINAL INJURIES
These are for doubtful or difficult cases only. Where there are signs that indicate the need for a laparotomy, these methods are quite unnecessary. A positive result in any of them is an indication for an abdominal injury.
TEST FOR ORTHOSTATIC HYPOTENSION This may be useful
i f a patient has no other obvious cause of blood loss.
Take his pulse and blood pressure while he is lying flat.
Then take it again when he is sitting up. While he is lying flat,
his circulation may seem to be compensated. But sitting him
up may produce a sharp fall in blood pressure, and an increase
i n his pulse rate. This shows that his blood volume is depleted.
TEST FOR INCREASING GIRTH Note any initial distension
and measure the patient's abdomen with a tape measure at
his umbilicus. An increase in his girth will be a useful sign
of the paralytic ileus that follows peritonitis or
haemoperitoneum. So take a base line measurement now. An
increase of only 2 or 3 cm indicates a large amount of
abdominal fluid or gas. This test only works if: (1) You always
measure his girth at the same place (mark it on his skin with
a pen). (2) He has a nasogastric tube down. Without a
nasogastric tube, swallowed air in his stomach can cause a
false positive result. It will also prevent acute gastric dilatation,
which may mimic a more serious lesion.
DIAGNOSTIC PARACENTESIS ('Four quadrant tap') This is
a useful rapid test. Some surgeons omit it and proceed
immediately with peritoneal lavage.
Take a syringe and a 1.4 mm needle. Under local anaesthesia, or no anaesthesia at all, and using an aseptic no-touch technique, tap all four quadrants of the patient's abdomen as in Fig. 66-3. Push the needle through his abdominal wall until the sudden give shows that you are just inside his peritoneal cavity, then aspirate.
If aspiration is negative, take the needle out, roll him towards the side of the suspected injury, and repeat the test.
If aspiration is still negative , repeat it in an hour or two, or try lavage as described below.
CAUTION ! (1) Although the blood from a haemoperitoneum i s usually defibrinated and does not clot, there is always a chance that it may do so. A negative result does not exclude an abdominal injury. If necessary, repeat the tap in an hour or two.
This test is useful on other occasions (6.2). You may occasionally aspirate urine (from a ruptured bladder), cloudy or bile stained fluid (from a perforated gut or peptic ulcer), or pus (in primary peritonitis). if you are in doubt, examine a Gram film, and look for bacteria, leucocytes, or food.
PERITONEAL LAVAGE Many surgeons would say that if
l avage is necessary, you should explore a patient's abdomen
anyway. An unnecessary lavage wastes time. Lavage is useful
if you are in doubt whether a laparotomy is necessary or not,
especially if: (1) A patient is unconscious and cannot complain
of pain. (2) He has multiple injuries and you want to
assess priorities. (3) You have to take him to the theatre to anaesthetize him for some other procedure, and if there is
any suspicion that he might have an abdominal injury.
Catheterize his bladder. Prepare and drape his abdomen. Use lignocaine to infiltrate an area in the midline 2.5 cm below his umbilicus down to his peritoneum.
Use a scalpel to make a small nick down to his peritoneum. Using turning movements, push a trocar and cannula into his abdominal wall.'You will feel a sudden 'give' as it goes into his abdomen.
Ideally, push a peritoneal dialysis catheter through the cannula and then withdraw the cannula. Or, use the tubing from an infusion set with a few extra side holes cut near its tip.
If blood flows up through the tube, you have confirmed a haemoperitoneum.
If nothing happens, connect the cannula or tube to a drip set and infuse 500 ml of warm saline into his peritoneal cavity for 10 minutes. While this is going in, tilt him up and down and from side to side to spread the saline round his abdominal cavity.
Lower the infusion bottle to the floor before it is completely empty, so that some saline syphons back. If blood or bile comes back in the fluid, he has an abdominal injury. The test is a little oversensitive: a trace of blood in the saline is unimportant. But, it you cannot read newsprint through the clear plastic tubing, he needs a laparotomy.
CAUTION ! A negative result does not exclude an abdominal injury.
CULDOCENTESIS is one of the most useful and accurate
ways of confirming intraperitoneal bleeding in a woman (Fig.
16-4). If you aspirate more than 1 or 2 ml of blood which does
not clot, she has a haemoperitoneum.
OTHER TESTS IN AN ABDOMINAL INJURY
URINE Examine this for blood from a bruised kidney or a ruptured bladder.
WHITE CELL COUNT A leucocytosis of 15,000 or more . s
common with a haemoperitoneum. The rupture of a hollo
viscus does not usually raise the white count so high. A
leucocytosis is more useful than a low haemoglobin or
haematocrit. A patient will not become anaemic until there
has been time for his blood to dilute.
X-RAYS Take erect films of a patient's chest and abdomen.
If he cannot sit up, take a lateral film while he is lying on his
side. Another good X-ray is to turn the patient on his left side
and take an AP view of his liver area.
Look for: (1) His stomach and splenic flexure pushed medially. (2) Herniated viscera in his pleural cavities due to rupture of his diaphragm. (3) Fractures of his lower ribs, suggesting a crush injury to his spleen or liver. (4) Gas under his diaphragm, as in Fig. 66-4, indicating rupture of his gut. (5) Peritoneal effusions. (6) Bullets or foreign bodies. (7) Fluid (or fluid and air) in his pleural cavities. These are signs of a thoracic injury. If you suspect he has ruptured his bladder or urethra, X-ray his pelvis. (8) A grey 'ground glass' appearance between loops of small gut may be the first sign of a haemoperitoneum.
Ruptured spleen Signs include: (1) A raised left
hemidiaphragm. (2) Indentation of his stomach. (3) An opacity
in his left hypochondrium. (4) His transverse colon displaced
downwards. (5) Displacement of his gastric gas shadow.
Always review X-ray films in the light of what subsequently happened. Next time you will recognize the signs in time.
THE MANAGEMENT OF ABDOMINAL INJURIES
The critical question is, should you do a laparotomy or not? Close observation and repeated examination is the main way to decide this. If you decide to do one, goto Section 66.2 for a penetrating injury, and to 66.3 for a blunt one.
Examine the patient every half hour. Watch for a rising pulse, restlessness, an increase in his girth, and deterioration in his general condition. It may be stable for a long time and then deteriorate rapidly. Don't wait too long, because the difference between the results of the best and the worst surgery is much less than that between early and late surgery.
CAUTION ! (1) If you do decide to operate, do so immediately. Don't delay longer than is necessary to organize the theatre and cross match more blood. (2) If you are in doubt as to whether to operate or not, be safe-operate.
REFERRAL Either refer the patient immediately, so that he
can be operated on in a few hours, or operate yourself.
THE FURTHER MANAGEMENT OF ABDOMINAL INJURIES
Read on for: penetrating abdominal injuries (66.2), laparotomy (66.3), rupture of a patient's abdominal wall (66.4), rupture of his diaphragm (66.5), rupture of his spleen (66.6), rupture of his liver (66.7), stomach injuries (66.8), small gut injuries (66.9), injuries to his mesentery (66.10), large gut injuries (66.11), injuries of his caecum (66.12), injuries of his right colon (66.13), injuries of his transverse and descending colon (66.14), rectal injuries (66.15), duodenal injuries (66.16), pancreatic injuries (66.17), gall bladder injuries (66.18), other difficulties with an abdominal injury (66.19).
If a patient is unconscious , the diagnosis of abdominal bleeding will be difficult. Look for: abdominal distension, fluid i n his abdomen as shown by shifting dullness, absent bowel sounds, a positive test on paracentesis, a fall in blood pressure, an unaccountable loss of blood (53.2), and the development of oliguria. These are all gross signs when well developed, so watch for them in their earliest stages.
If he develops an lieus or acute intestinal obstruction a few days after admission, operate, he may have an intestinal injury and be developing peritonitis. For more difficulties, goto Section 66.19.
IF YOU ARE IN DOUBT, ADMIT AND OBSERVE HIM, AND EXAMINE HIM REPEATEDLY IF THERE IS ANY SUSPICION OF AN INTRA-ABDOMINAL INJURY, OPERATE
Penetrating abdominal injuries
PENETRATING ABDOMINAL INJURIES
If a patient has an abdominal skin wound the important questions to decide are: (1) Has it entered his peritoneal cavity? (2) Has it done any damage which requires surgery? Knives, bullets, or the horn of an animal can all penetrate the abdomen. It is the depth of a wound that matters, not its length. More severe injuries are often multiple and may penetrate a patient's thorax as well as his abdomen, as with the arrow in Fig. 66-6. Stab wounds and bullet wounds differ. Stab wounds from knives and daggers follow a predictable path; only the organs through which the weapon passes are injured, and a laparotomy may not be necessary. Bullets may follow an unpredictable path, may change direction, and cause widespread damage. The higher their velocity the worse this is. Bullets almost always cause serious visceral injuries, so operate on all bullet wounds. If you select patients with penetrating wounds wisely, and observe them all carefully, about a third of them will not need a laparotomy. Be guided by the nature of the injury and the force used. If you try to treat a patient conservatively, monitor him carefully. Increasing pain, shock, and signs of peritonitis will tell you when to operate. Time is critical. Few patients survive if peritonitis has been developing for 16 hours, but most will live if you can operate in the first 6 hours. Before starting to operate on a patient with a bullet wound, think carefully about the structures that it may have injured in its path between entering and leaving the abdomen. If it remains inside, see where it is in at least two X-rays taken from different A patient may be grateful for the time you spend reviewing his anatomy.
AMOS (6 years) was playing on a child's slide. He went down on his front, feet first, and subsequently complained of abdominal pain. There was a small lacerated wound on his abdominal wall near his umbilicus. The signs o£ general peritonitis developed and laparotomy showed a splinter of wood 15 cm long and 3 cm wide, which had entered his abdomen and penetrated the anterior wall of his stomach. This was removed and he recovered.
PENETRATING ABDOMINAL INJURIES
This extends the general method for abdominal injuries in Section 66.1. Much of the section on blunt injuries (66.3), and eviscerating injuries (66.4), also applies. If a knife, or any other penetrating object, is still in place, leave it there until you reach the theatre, as in Figs. 66-5 and 66-6. Work out the track of the wound. Wounds can enter a patient's abdomen from his back, his chest, his buttocks, or his thigh. If he might have a thoraco-abdominal injury, examine him for a haemothorax, or a haemopneumothorax (65.4). Look for blood in the patient's urine and gastric aspirate. If he has haematuria, do an intravenous pyelogram.
THE CONSERVATIVE TREATMENT OF PENETRATING ABDOMINAL INJURIES
In the absence of any of the indications for laparotomy listed in Section 66.3, you may be able to manage a patient with a stab wound conservatively. Record his pulse and blood pressure half hourly. Watch him closely. Operate if he shows signs of bleeding or peritoneal irritation.
THE OPERATIVE TREATMENT OF PENETRATING ABDOMINAL INJURIES LOCAL TREATMENT ABDOMINAL INJURIES
When you operate, explore the patient's stab wound in the theatre and excise it down to his peritoneum. Open up the plane between his transversus and his peritoneum over a reasonable area and look at it.
If his peritoneum is intact, close his wound by immediate or delayed primary suture.
If his peritoneum has been opened, do a laparotomy, through a standard incision, and examine any organ which might have been injured.
If a plug of omentum protrudes through the wound, enlarge it, explore it, and make sure there are no injured viscera underneath.
If you have to get into his abdomen in a hurry, make a long midline or paramedian incision.
CAUTION ! As a general rule, don't try to explore the abdomen by extending the wound from the original injury. You will run into anatomical difficulties. Make a separate laparotomy incision. Continue as with a laparotomy for a blunt injury, as described in the next section. Always try to close the patient's peritoneum. Close the muscle layers as best you can. If necessary, you can close them as a single layer. if the skin wound of the original injury was contaminated, leave it open for delayed primary suture.
If you cannot close the peritoneum, goto Section 66.4.
Laparotomy for abdominal injuries
If you suspect that a patient might have an abdominal injury, don't be afraid to do a laparotomy, and don't delay. An occasional negative laparotomy is better than always waiting for some obvious indication of an abdominal injury. He will not die from a big incision, but he will die if you overlook a serious injury. If necessary, watch him carefully for at least 24 hours. The commonest causes of a haemoperitoneum are injuries to a patient's spleen, liver, and mesentery. So search for them in that order. Even if you find no free blood or intestinal contents, he may still have a small perforation, which is temporarily sealed off. So search his abdominal organs carefully. Try to find and treat all the patient's injuries. Don't try to do this through an incision which is much too small. Although he may only have a tiny bullet hole in his abdominal wall, you will probably need a long incision to find all the harm it has done. Adequate exposure may save your time and his life. Severe haemorrhage can be difficult to control. The secret is to control it temporarily with pressure, packing, and patienceespecially patience. Then, slowly and carefully try to find the bleeding site. This is much better than frantic efforts to clamp bleeding points, regardless of the blood that is being lost while you try to do this. If bleeding is so severe that blood wells up in the wound, try packing, and pressure, if necessary on a major vessel. Be patient, and find another assistant to help you. Good relaxation will make the bleeding site easier to find; so will packing away the viscera, extending your incision, and tilting the table.
FIND AND TREAT ALL INJURIES
' PRESSURE, PACKING AND PATIENCE'
LAPAROTOMY FOR AN ABDOMINAL INJURY
Here are the common steps in any abdominal injury. Read on for the care of particular injuries. If the patient has a penetrating injury„consult Section 66.2 first.
INDICATIONS FOR LAPAROTOMY Always do an early laparotomy for: (1) Signs of internal bleeding, as shown by a rising pulse rate, restlessness, and pallor. (2) Increasing guarding, tenderness (including rebound tenderness) or rigidity (regardless of the bowel sounds). (3) All bullet and grenade wounds. (4) Herniation of a patient's viscera through his diaphragm, or his abdominal wall, even if there is only a tag of omentum protruding. (5) Thoraco-abdominal wounds. (6) Haematemesis, blood in his gastric aspirate (provided this is not obviously from his mouth or nose), or rectal bleeding. (7) Penetrating anal or vaginal injuries. (8) Positive findings on paracentesis or gastric lavage, or an increasing girth. Many stab wounds don't need a laparotomy (66.2).
CAUTION ! (1) More harm is done by not exploring than by doing so. (2) You will not know the extent of an abdominal injury until you get inside the patient's abdomen, so, if referral is possible, you may be wise to resuscitate a patient with fluid and blood and refer him.
RESUSCITATION Set up a really good intravenous drip (A 15.2). Cross-match several units of blood. If this is scarce, and the patient's condition allows it, don't give it until you have clamped the bleeding vessel. Meanwhile give him Ringer's l actate or saline; if necessary, give him 3 or 4 litres of fluid over an hour or two as in Section 53.2.
CAUTION ! Operate as soon as you have got the maximum benefit from resuscitation. But if bleeding exceeds all your efforts at blood replacment, operate urgently to control it.
EQUIPMENT A general set (4.11). Use long instruments to enable you to work deep in the patient's abdominal cavity. Have the equipment for autotransfusion ready (16.11). Effective suction is essential. Find a strong assistant to help with traction.
GASTRIC ASPIRATION If you have not already aspirated the patient's stomach, do so and leave the tube in. An empty stomach will make splenectomy easier. In bladder injuries, pass a Foley catheter and leave that in too.
PEROPERATIVE ANTIBIOTICS If the patient's peritoneal cavity does become infected, Gram negative bacilli and anaero bes will probably be responsible-see Section 2.7. Timing is critical. Give him chloramphenicol with metronidazole. Give these intravenously as soon as you suspect contamination- of his peritoneal cavity from rupture of his gut. Give them with the premedication.
If laparotomy shows no contamination, stop them
If contamination of the peritoneum occurs during surgery, but is not going to continue, as with resection of the colon, stop the patient's antibiotics after 12 hours.
If there is established infection, as with a perforation of 8 hours duration or more, continue antibiotics for 5 days.
CAUTION ! (1) It is much more important to start antibiotics early than to continue for long. Starting them after the patient returns to the ward is certainly too late. (2) This perioperative regime is always indicated if the operative field is, or will be, significantly contaminated. (3) Avoid gentamicin because it interferes with the reversal of some relaxants (A 14.3).
ANAESTHESIA The patient's stomach may be full of food and drink. You will need good muscular relaxation. So a combination of ketamine, suxamethonium, cricoid pressure, intubation, gallamine, and ether or trichlorothylene is probably best (A 14.3). Don't give him a relaxant until you are ready to open his abdomen and tie the bleeding vessel. The relaxant may promote bleeding by destroying the splinting effect of his muscles.
If a patient is drowsy from a head injury, and needs a laparotomy, don't be deterred from giving him a general anaesthetic.
If a patient's respiration is embarrassed because there is much blood in his pleural cavity, drain it under local anaesthesia, before you anaesthetize him. If an intercostal drain does not improve his respiration adequately, he should, ideally, have a thoracotomy before his laparotomy.
If he is so weak that he will not withstand a general anaesthetic, you may have to operate under local anaesthesia.
OTHER WOUNDS If a patient has serious wounds on his back explore these first. The problem if you leave them until last, is that he may not tolerate lying on his front after a long abdominal operation.
INCISIONS FOR BLUNT INJURIES Aim to get inside the patient's abdomen fast; you can tie bleeding vessels in his abdominal wall later. In general, make a midline or right rectus retracting or rectus splitting incision. Vertical extensions to an incision are easier to close than horizontal ones. So, if necessary, extend a vertical incision from a patient's xiphoid to his pubis. If you want even more exposure, make a T-shaped incision into either flank.
If the injury is in the patient's lower left chest, and the signs indicate a ruptured spleen, make a left upper paramedian incision. If exposure is inadequate, extend it towards his left costal margin. If necessary, with any incision, tilt the table to make access easier.
INSIDE AN INJURED ABDOMEN
Have the sucker ready as you get inside the patient's abdomen. Watch for a puff of gas as you open it. This indicates an injury of his gut. If the gas smells faecal, he has injured his colon.
If there is blood in his left hypochondrium, you can be almost sure that he has ruptured his spleen. If there is blood in his right hypochondrium, his liver is probably ruptured.
If there is blood in the middle of his abdomen, his mesentery may have been injured.
If there is bile in his peritoneal cavity (66.18), examine his gall bladder, his duodenum, the rest of his upper small gut, his cystic duct, his common bile duct, and his hepatic ducts.
If there is blood, intestinal juice, and bile in his peritonal cavity, he has probably torn his small gut. Quickly suck away any free blood and intestinal contents. If you are going to use the blood for autotransfusion, see Section 16.11.
CAUTION ! If the blood in his peritoneal cavity is contaminated by bile or intestinal or pancreatic secretions, don't use it for autotransfusion.
CONTROL BLEEDING Do this before you examine the patient's viscera. If necessary: (1) Grasp or put a clamp across his splenic pedicle. (2) Clamp his mesentery. (3) Pinch the vessels in the free edge of his lesser omentum with your finger in his epiploic foramen. Suck out the blood from his abdomen.
EXAMINING THE VISCERA IN AN ABDOMINAL INJURY
Examine the patient's abdominal organs systematically. Diagram D in Fig. 66-7 shows one pathway for doing so. Most surgeons have their own routine. Whatever routine you choose, be sure to examine everything. Unless you find some major bleeding, such as from a ruptured spleen, complete your examination before starting to do any repairs. If you find an injury to the patient's small gut or mesentery, clamp it with a soft intestinal clamp, so that you can easily find it, making sure that it does not leak while you continue your search.
If there is any possibility of an injury to the posterior wall of the patient's stomach or the peritoneum behind it, detach his omentum from the anterior surface of his colon. It has almost no blood vessels. Open his lesser sac, and look at the back of his stomach, the back of his transverse colon, and the front of his pancreas.
If you have reason to suspect that the second part of his duodenum might be injured, (for example, you might see a retroperitoneal haematoma) incise the parietal peritoneum lateral to it, elevate his duodenum, and inspect its posterior wall. Look for retroperitoneal bruising over the patient's ascending and descending colon. If necessary, you can reflect his ascending or descending colon by making incisions in his paracolic gutters, and reflecting part of his colon forwards, as in K, and L, Fig. 66-8. If necessary, you can reflect his duodenum forwards, as in M, Fig. 66-8.
CAUTION ! Don't be content with finding only one injury. He may have many, especially if he has a gunshot injury.
RETROPERITONEAL INJURIES Management depends on the site of the injury.
If the patient has a retroperitoneal haematoma in his flank, it is probably coming from his kidney (67.1). If possible, leave it. Don't open any retroperitoneal haematoma, unless you are obliged to.
If he has a haematoma near his duodenum or colon, these organs are probably injured retroperitoneally and need to be explored, if possible without contaminating the adjacent peritoneal cavity. For haematomas of the mesentery and pelvic mesocolon, goto Section 66.10.
GUNSHOT WOUNDS Search meticulously for entry and exit wounds in anything that might have been injured. Small bullet wounds in the gut may seal themselves off temporarily. Bullet holes in the colon may be covered with a sheet of omentum which you must lift to find them.
INJURIES TO PARTICULAR VISCERA A a blunt injury is likely to have injured these organs in order of decreasing frequency: the spleen (66.6), the liver (66.7 ), the mesentery (66.10), the small gut (66.9), the colon (66.11), the kidneys (67.1), or the duodenum and Pancreas (66.16 and 66.17).
CLOSING THE ABDOMEN AFTER A LAPAROTOMY
The danger of peritonitis will be reduced if you remove as much pus, intestinal contents, faeces, and blood as you can. So irrigate the patient's peritoneal cavity with warm saline before you close it. See Section 6.2. If you don't have any warm saline, mop it out as best you can. CAUTION ! Bleeding must be completely controlled. When you have closed the patient's peritoneum, irrigate the structures of his abdominal wall thoroughly, and close it with tension sutures of monofilament or stainless steel. if necessary, close it in a single layer.
If there is much infection, and you expect the wound to disrupt, close the muscles of his abdominal wall with interrupted stainless steel wire or deep tension sutures, and his skin by delayed primary closure, as in Section 9.7. I f infection is present, or you expect it to develop, insert one or more drains through separate incisions. Use wide bore tubes, such as 30 Ch catheters and lead them into sterile bags or bottles (9.7).
RECORDS Sign the patient's notes to the effect that you have examined, and either dealt with or found normal, his diaphragm, stomach, spleen, liver (both surfaces), large gut (including his splenic and hepatic flexures), entire small gut, rectum, bladder, pancreas, kidneys, ureters, and a woman's gynaecological organs. Many surgeons prefer this order of examination to that in Fig. 66-7, and some have a rubber stamp made to this effect.
POSTOPERATIVE CARE Monitor the patient's haemoglobin, and correct his anaemia by transfusion. Continue intravenous fluids and nasogastric suction until bowel function is restablished. His bowel may be paralysed for many days, so monitor his fluid and electrolyte balance carefully. Watch for pelvic and subphrenic abscesses (6.3).
EXPLORE THE ABDOMEN IN A LOGICAL WAY
Rupture of the abdominal wall (evisceration of the gut)
How are you going to treat a patient who has been gored by a buffalo so severely that gut prolapses through his wounded abdomen? Fortunately, the treatment of this alarming injury is usually straightforward. To begin with he may not be very shocked. Later, loop(s) of gut may strangulate and cause severe shock. Sometimes his injured gut leaks.
EVISCERATED GUT AFTER AN ABDOMINAL INJURY
Resuscitate the patient, pass a nasogastric tube. Cover the exposed loops of gut with a warm saline pack or a towel.
If the patient's gut is strangulating, immediately enlarge his wound under local infiltration anaesthesia (A 5.4) to relieve it.
If his gut is injured and leaking, you can, if necessary, close it temporarily with a non-crushing clamp, or resect it before anaesthetizing him. Gut is insensitive, so he will feel nothing. This will prevent later soiling of the wound. Anaesthetize him-you will need good muscular relaxation. Paint his abdomen with some gentle antiseptic, such as chlorhexidine- and irrigate the exposed loops of his gut with quantities of saline. Enlarge his wound in the most appropriate direction to make an incision which most nearly approximates to one of the standard ones, or do a separate standard laparotomy, taking care to miss nothing. You may find several other injuries. if necessary, revise the emergency closures that you did earlier. To do so, empty the injured section of gut, and apply soft clamps across its base to prevent it filling. Then undo any temporary sutures, freshen the edges of his gut, excise anydamaged areas, and do a formal closure or resection, as in Section 9.3. Always try to close a patient's peritoneum. Close the muscle layers as best you can, and leave his skin open for delayed primary suture. Excise the margins of the original wound.
If returning his viscera to his abdomen and closing it is difficult, try decompressing his small gut. Milk its contents proximally into his stomach, and keep aspirating all the time with a nasogastric tube.
If you cannot close his peritoneum (very unusual), try making long relieving incisions on the sides of his abdomen so that you can close his skin and subcutaneous tissues. Later, refer him for the repair of the muscles of his abdominal wall.
Alternatively: (1) Cover the wound with moist packs. The organs which present in it will granulate, and you can graft them about the fifth day. Refer him for a formal repair later. Or, (2) make an artificial peritoneum with strong, sterile cloth heavily coated with sterile vaseline, sewn to the margin of the defect. Granulations will slowly grow over it from the edges. Leave the cloth prosthesis in for several days and repeat the procedure as necessary. Graft the granulations with split skin, pending a formal repair.
Rupture of the diaphragm
A patient's diaphragm more commonly ruptures on the left, so that his viscera herniate into his left chest. This is fortunate, because injuries on the left are more easily repaired. Sometimes his injury is so severe that he can hardly breathe, or it can be so mild that it may not be discovered for several weeks. Exclude rupture of the diaphragm by taking a routine chest X-ray. There are sure to be other injuries also.
RUPTURE OF THE DIAPHRAGM
This is not an easy operation, refer the patient if you can.
If the patient is severely dyspnoeic, try emptying his stomach with a nasogastric tube.
ANAESTHESIA Insert an intercostal drain and anchor it securely to the patient's chest. Give him a general anaesthetic, intubate him, and if possible give him a long-acting relaxant. Avoid distending his stomach.
LAPAROTOMY Divide the left triangular ligament of the patient's liver and draw its left lobe downwards and to the right. Pull his abdominal viscera out of his chest. Retract the torn margins of his diaphragm downwards, and repair it with heavy interrupted non-absorbable sutures. Use the long ends of each stitch for gentle traction, until you insert the next one. The tear usually extends to his oesophageal hiatus. Repair this with special care. Connect his chest drain to an underwater seal bottle (65.2), and remove it at 48 hours.
Injuries of the spleen
Rupture of a patient's spleen gives you one of your best chances of saving his life, and is the major indication for splenectomy in a district hospital. Big malarial spleens rupture readily, but big schistosomal spleens do not. If a patient ruptures his spleen, you will not have time to refer him. To succeed, you will need to make the diagnosis promptly, resuscitate him vigorously, operate immediately, and expose his spleen adequately. Emergency splenectomy can be difficult, especially when his spleen has stuck to his diaphragm by dense vascular adhesions which bleed briskly. Usually, a patient's spleen is only torn, but it may be shattered, pulped, or completely avulsed from its pedicle. Symptoms usually develop rapidly, but they may occasionally be delayed for a few hours. Rarely, a haematoma seals off bleeding to begin with, and then suddenly bursts. When this happens, symptoms may be delayed several days or even weeks. The common mistake is to delay making the diagnosis until too late. Maintain the patient's blood volume. First, give him saline or Ringer's lactate. Then, when you have controlled his bleeding splenic pedicle, give him blood (53.2). Operate urgently.
DELAY IS THE COMMONEST ERROR, EVERY MINUTE MATTERS
The splenic pedicle is in two parts: (1) A fold of peritoneum, the lienorenal ligament, stretches across from its hilum towards the surface of the kidney. In it run the splenic artery and vein, and often the tail of the pancreas also. (2) A second fold of peritoneum, the gastrosplenic ligament, joins the hilum of the spleen to the greater curvature of the stomach. In it run the short gastric arteries. These two ligaments unite to form the pedicle of the spleen. Between them lies the extreme left edge of the lesser sac. You can compress the vessels in the splenic pedicle between two fingers, and so stop a spleen bleeding. Controlling bleeding is the main difficulty. It will be easier if you have good exposure. If you find a huge haematoma, tying off the patient's whole splenic pedicle without first identifying the vessels may be life-saving. But there is a danger that you may tie the tail of his pancreas, or even a fold of his stomach or colon, as you do so. The ligatures are also more likely to slip. The spleen is not quite the disposable organ that it was once thought to be. The risks of removing it include overwhelming infection, and reduced immunity to malaria, particularly in children. The easiest way of conserving some splenic tissues is to put a few slices under a covering of peritoneum below the left costal margin. In the following method we advise you to start by opening the gastrosplenic ligament, then tying the splenic artery before rotating the spleen medially, and tying and dividing the vessels in its pedicle individually. In desperation you can start by putting a ligature round the entire splenic pedicle.
RUPTURED SPLEEN
For earlier steps in the operation see Section 66.3. Make sure the patient has a nasogastric tube in his stomach, and a free flowing drip in a big vein.
ANAESTHESIA Good relaxation is necessary. (1) A ketamine drip with a relaxant. (2) Ketamine induction followed by ether with a relaxant. In a grave emergency, when a patient is desperately ill, you may have to remove his spleen under local anaesthesia.
POSITION Lie the patient on his back with his left arm drawn over to his right and his forearm supported on a pad or arm rest. It is sometimes helpful to rotate his thorax to the right with a sandbag under his left chest and pelvis.
INCISION If you are sure that a patient's spleen has ruptured, make a left paramedian, rectus split, or upper midline incision. Otherwise, make a right paramedian or a midline incision.
File:Fig 66-11 EMERGENCY SPLENECTOMY
CONFIRM THAT THE SPLEEN HAS BEEN INJURED
Fresh blood or clots in a patient's left hypochondrium nearly always mean that his spleen has ruptured. Confirm this by feeling its surface. It should have a smooth surface facing his diaphragm, and a notch on its anterior border. The injury may have torn any of its surfaces, or pulled it off its pedicle. If it is damaged in any way, remove it. If you are not sure if it has been injured or not, extend the incision. Control bleeding temporarily by compressing his splenic pedicle between the thumb and fingers of your left hand. Save as much blood as you can for autotransfusion (16.11). Keep holding the pedicle until the anaesthetist confirms that the patient is in a satisfactory condition to proceed. First get at his injured spleen: (1) Tilt him on to his right side. (2) Pack his stomach and his transerve colon out of the way. Ask a strong assistant with a large left hand to draw the patient's stomach and colon downwards, and retract his left costal margin upwards. (3) If necessary, and especially if there are dense adhesions between the spleen and the diaphragm or abdominal wall, extend the incision. Extend a midline incision laterally, by cutting his left rectus through one of its ten. dinous insertions. If necessary, cut beyond its outer borders. If you cannot find a tear, look elsewhere in the patient's abdomen. If you still cannot find a tear, return to his spleen, and examine it with more care.
TIE THE SPLENIC PEDICLE
If you are inexperienced and bleeding is severe, deliver the patient's spleen, rotate it forwards, and to the right. Put a thick ligature right round the entire splenic pedicle. This is safer than trying to grasp it with a large clamp. As you do so, try not to damage his stomach, and to cause the least possible damage to his pancreas. When you have controlled bleeding, proceed to tie the vessels individually.
If you are more experienced, use blunt scissors to open up a window in his gastrosplenic ligament, as in B, Fig. 6& 11. This will let you into his lesser sac. Feel for his splenic artery along the upper border of his pancreas. Incise the peritoneum over it, pass a haemostat underneath it, and tieit. Don't divide his splenic artery yet; his splenic vein lies under it -avoid injuring this. Clamp, cut, and tie his short gastric vessels passing from his spleen to the greater curvatureof his stomach. Tie them individually using small artery forceps If you tear them, oversew the wall of his stomach with atraumatic sutures.
CAUTION ! Don't include an area of stomach wall with your ligatures, especially at the upper margin of the spleen.
FREE THE PATIENT'S SPLEEN Feel for his spleen by putting your hand under his diaphragm, and breaking down any light adhesions.
If adhesions are dense, cut them with long curved Metzenbaum scissors, or incise the peritoneum and separate his spleen from his diaphragm extraperitoneally. Rotate his spleen gently downwards and medially (C). Incise his splenorenal ligament (D). Put your finger into the peritoneal opening and gently free its margin. You can now bring his spleen well outside his abdomen (E). Divide his splenocoiic ligament between curved clamps, taking care to avoid clamping his colon (F). Reflect his spleen medially and use blunt dissection to separate the tail of his pancreas from his splenic vessels (G). Tie them at the splenic pedicle just before they divide. Clamp the vessels in his splenic pedicle (H). Pass ligatures of No. 1 linen thread or silk under the vessels of the pedicle, and tie them securely. For extra security apply a second set of ligatures at the same point.
CAUTION ! Make sure your assistant releases the haemostats gently and steadily, as you tighten the ligature, without asudden click. If the cut vessel drops off and is lost in a pool of blood, you may never find it again. Bleeding vessels on the diaphragm are small, very persistent, and almost impossible to tie. If possible, use diathermy. Absolute haemostasis is essential. Put a big dry pack over the patient's splenic bed. Leave it there for a few minutes. Remove it and look for any bleeding vessels, and tie them off. Look for other abdominal injuries before you close his abdomen.
AUTOTRANSPLANTATION Use a large scalpel to cut two large thin 2 mm slices from the patient's spleen. Incise his parietal peritoneum under his left costal margin, slip the slices in, tie them flat against his intercostal muscles, and sew up the peritoneum over them. If, 4 weeks later, he has no Howell Jolly bodies, and no target cells in his peripheral blood film, and his platelet count is normal, transplantation has probably succeeded.
DRAINS If: (1) the operative site is absolutely dry, and (2) you are sure you have not injured the tail of the pancreas, there is no need for a drain. Otherwise, place a large corrugated or tube drain down to the tail of the pancreas, and close the wound.
DIFFICULTIES WITH EMERGENCY SPLENECTOMY
If OOZING IS UNCONTROLLABLE, insert a large pack and remove it 48 hours later.
If a PATIENT SUDDENLY DETERIORATES postoperatively, a ligature has probably slipped. Operate immediately.
If a SEROUS EFFUSION DEVELOPS in his splenic bed it may resemble a subphrenic abscess; but it usually resolves slowly and spontaneously. If X-rays show that his stomach continues to be displaced, the effusion may need draining.
If VENOUS THROMBOSES OCCUR, they may involve any vein, but they won't be disastrous unless they involve his portal vein. The platelet count always rises after splenectomy and then usually falls without reaching dangerous levels. If possible, check his platelet count at 4 and 8 days. If there are more than 750,000 platelets mm3 give him heparin (5,000 units every 4 hours intravenously depending on his size and his associated injuries).
If his WOUND SLOUGHS and there is a fluid discharge, the tail of his pancreas may have been injured. Reopen the wound and do a suture ligation of his damaged pancreas. I nsert a suction drain (9.7).
Liver injuries
Injuries to a patient's liver resemble those of his spleen with one critical difference-you can remove his entire spleen, but not his liver. Either massive bleeding kills him quickly, despite all you can do to resuscitate him, or signs of an intra-abdominal disaster develop more slowly. If blood immediately floods his whole peritoneal cavity, the signs are general; if bleeding is less severe, the signs are mostly on the right. Pain at the tip of his shoulder is less common than with rupture of his spleen. The right lobe of the liver is injured more often than the left. You may find: (1) A minor tear, usually without serious bleeding. Most stab wounds are like this. (2) Ragged lacerations with severe bleeding. (3) Tears of the patient's hepatic artery, his portal vein, or his hepatic veins or their major branches. Controlling haemorrhage from these vessels is desperately difficult, and most patients die even in expert hands. If his hepatic veins have been injured, a tape has to be passed round his vena cava above and below their point of entry. They then have to be exposed and sutured-a difficult task. Happily, not all liver injuries are impossibly difficult. The easier ways of controlling a bleeding liver are: (1) To pinch the vessels in the free edge of the patient's lesser omentum between your fingers temporarily. (2) To pack the tears with gauze for 24 to 36 hours. The main risk of doing this is that severe sepsis may follow. (3) To bind tears together with deep mattress sutures. (4) To use absorbable haemostatic gauze. Experts can excise large parts of the liver, or tie its arteries, relying on the fact that it has two blood supplies-arterial and portal. Even'so, their results are usually bad. The complications, particularly infection, are grave, but a live patient with complications is better than a dead one. The main way to prevent infection is to insert really adequate sump drains (4 to 6 Ch), so that as few clots as possible remain in the patient's abdomen to become infected.
RUPTURED LIVER
For earlier steps in the operation, see Section 66.3. Blood in the patient's night hypochrondrium is probably coming from his liven. If you have difficulty exposing it, make a T-shaped extension to the night of a median on paramedian incision.
If the patient's liver has stopped bleeding, when you examine it, leave it well alone, and merely drain it.
If his liver is bleeding severely, control it by pinching the free end of his lessen omentum, with your finger in his epiploic foramen (foramen of Winslow). Put your left index through the foramen behind his lessen omentum leaving your thumb in front of it. Pinch his portal vein, his hepatic artery (and his bile ducts) between your fingers. You have 15 minutes to enlarge the incision and get better access to the tear. if necessary, ask an assistant to hold the vessels while you operate.
CAUTION ! The liver can withstand 15 minutes of such ischaemia-not more.
Run your night hand oven the dome of the right lobe of the patient's liven and feel for tears, puncture wounds, nagged l acerations, and major blow-outs. Pass your hand as fan back as it will go behind the night lobe of his liven, as fan as the coronary ligament. Then move it to the left and explore the upper and lower surfaces of the left lobe of his liven in the same way.
SMALL LACERATIONS OF THE LIVER CAPSULE Drain them and leave them.
MINOR TEARS When you first feel a tear, pack it with gauze for 2 on 3 minutes. When you remove it, you can: (1) pick up the bleeding vessels, on (2) coagulate and tie them, on (3) occlude them with through-and-through mattress sutures.
RAGGED LACERATIONS If you are confident in your ability, use your finger and thumb to pinch off any unhealthy, nagged, discoloured pieces of liven. If you leave them they may encourage secondary haemorrhage and sepsis. Small blood vessels and bile ducts will be left behind when you pinch off the liven from around them, so tie on cauterize these. Having done this, you can use either mattress sutures on packs. If you can suture the capsule adequately, it will probably contain the haematoma inside. Don't try to cauterize large areas with diathermy. If you are less confident, suture the tear, on pack it without doing too much exploring.
A SUBCAPSULAR HAEMATOMA Empty this and oversew it to control bleeding.
SPECIAL METHODS FOR AN INJURED LIVER
Through-and-through mattress sutures are not easy. Use a large, semicircular, round bodied needle with No. 1 chromic catgut. Ideally, this should be a special liven needle with a blunt end. Make large through-and-through sutures, to join the edges of the tear together, as in D, and E, Fig. 66-13. Set the stitches back about 1 cm on more from the edge of the tear, and if necessary overlap them. If they cut through the patient's liven, tie them oven pieces of haemostatic gauze, on free strips of peritoneum, his rectus sheath, on even pieces of his skin. If possible, pack a piece of haemostatic gauze into a laceration before you suture it.
Packing is a very useful and easy method. Make the pack from a roll of sterile dry, wide gauze. Pack the gauze in one long length into the cavity, and bring the end out through the patient's abdominal wall (B). if you have to use more than one roll, knot them together, so that when you pull out one pack, the other will come out too. Remove the pack very carefully i n the theatre 48 hours later. If you are lucky, there will be no significant bleeding. Except for the smallest wounds insert a large drain to carry away blood and bile from the wound. Don't insert a drain into the bile duct.
DIFFICULTIES WITH LIVER INJURIES
If the patient's WOUND DISCHARGES BILE, he has a biliary fistula. This will take a long time to heal, so be patient. See Section 66.18. If he becomes JAUNDICED, he will probably live, provided he has no other complications. Postoperative jaundice is common in major liven injuries, and usually resolves in about 2 weeks. If there is a HUGE TEAR in the right lobe of his liver, and its inside feel like porridge, gently scoop it out and remove any broken bits with your fingers. Then put in a huge dry gauze pack. You will need several metres of 10 cm bandages. Alternatively line the cavity with a piece of sterile plastic sheet and fill this with packs. Remove the packs (and the sheet) later. He may live after recovering from many complications, both early and late, including a subphrenic abscess.
Stomach injuries
The stomach can be penetrated by a missile or by a stab wound. It is very vascular, and its mucosa readily bleeds, so suture it with a continuous suture which compresses the whole length of its mucosal edge.
STOMACH INJURIES
Examine both surfaces of the patient's stomach by opening his lessen sac through his gastrocolic omentum as in C, Fig. 66-14, and turning his stomach upwards so that you can inspect its posterior wall. First trim the hole, to make sure you are suturing viable mucosa with clean cut edges. Use 2/0 chromic catgut to close the wound in two layers. Make the first layer an all coats, continuous inventing suture. Make the second layer of continuous Lembert seromuscular sutures (9.3). Close the wound as if you were closing the small gut, except that there is no need for the closure to be transverse to the stomach.
Alternatively, insert a catgut stitch at one end of the hole, and tie it. Now put a running stitch in and out of the stomach all round the hole, closing it as you do so. Put your thumb into the hole to invent the mucosa as you pull up the stitches (this kind of suture does not invert automatically). If possible, try to get all the mucosa inside the stomach. When you have tied the knot, you have closed the hole. Hide the all coats layer of sutures with an extra layer of Lembent sutures (9.3).
Small gut injuries
Penetrating injuries from bullets or knives can make holes in a patient's small gut and its mesentery. Blunt injuries either tear or burst it by pressing it against his spine. A patient's abdomen becomes tender after an abdominal injury. You may have difficulty deciding how much of this tenderness is caused by bruising of his abdominal wall, and how much by peritonitis from a ruptured gut. If you are in doubt, the decision not to operate is much more dangerous. Provided the small gut is viable, it has remarkable powers of repair. Although it may look very deformed and constricted at the end of the operation, it may be quite normal some months later. Although resecting gut does not increase mortality in skilled hands, it does so in less skilled ones. The main danger is a leak, because of poor technique, or sloughing of its wall. If you have a choice, repairing gut is safer than resecting it.
IF IN DOUBT OPERATE
SMALL GUT INJURIES
For earlier steps in the operation, see Section 66.3. For methods of resecting gut, see Section 9.3.
If, when you open the abdomen, there is a moderate amount of blood mixed with bile and intestinal juices, the patient's small gut has been perforated.
If there is no free fluid in his peritoneal cavity, his gut may still have been perforated, so search it carefully. In early cases ileus may minimize the leak. Search the patient's small gut from end to end. Feel for its upper end, deliver it into the wound, search it carefully on both sides, and return it to his abdomen. Do the same with succeeding loops, until you reach his iliocaecal junction. Look carefully at his proximal jejunum, and his terminal ileum, because they are particularly likely to be injured. Be prepared to find several holes! When you find a rupture, take care not to lose it again, while you search for others. Wrap it in an abdominal pack, and hold it aside in a light clamp. To see if a clamp is light, try it on your little finger. If it crushes this, it is not light. Gut is normally sewn in two layers as in Section 9.3, the buried one to control bleeding, and the superficial serosal one to hold the gut together. However, these wounds rarely bleed by the time you see them, so you can use one layer, if you wish.
Tiny holes Use a purse string suture, and oversew this with Lembert sutures.
Larger holes Use 2/0 chromic catgut on atraumatic needles to make a double layer of inverting sutures, in the transverse axis of the gut, as in Section 9.3.
Large ragged tears, dead or dying gut, or multiple adjacent perforations Resect through healthy gut and anastomose it end-to--end. Suture the mesentery accurately, and avoid injuring its blood vessels.
Small areas of bruising without perforations Infold these with Lembert sutures (9.3), or cover them with,omentum. Don't detatch this, leave it with its own blood supply.
If mesentery is injured, goto the next Section. Drain the patient's peritoneal cavity, and complete the laparotomy.
IF GUT IS DOUBTFULLY VIABLE, EXCISE IT
Injuries to the mesentery
An injured mesentery can bleed profusely after an open or a closed injury, and bleeding has little tendency to stop. The mesentery is usually injured near its relatively fixed top and bottom ends. When you examine it you may find a tear or a haematoma. Short tears are not serious, especially if they are perpendicular to the patient's gut, as in G, Fig. 66-15. The danger in sewing a tear is that you may include the vessels supplying the gut in your sutures, and so impair its blood supply. Vessels approach the gut from the mesentery. Because there is very little circulation along the length of the gut, tears close to its mesenteric border and parallel to it are particularly dangerous. Some haematomas limit themselves, and don't need treatment. Others expand, compress the vessels in the mesentery, and impair the blood supply to the gut. The difficulty is knowing what they are going to do. Opening a haematoma and trying to find the bleeding vessel increases blood loss, and risks damaging the vessel. Some surgeons leave haematomas alone. Others explore them to find the bleeding vessels, particularly if a haematoma is expanding. If the blood supply to a patient's gut is impaired, you will have to explore the bleeding vessel and, if necessary, resect his gut.
TEARS AND HAEMATOMAS OF THE MESENTERY
For the earlier steps in the operation, see Section 66.3. Suspect rupture of the mesentery if there is free bleeding in the centre of the patient's abdomen. Assess the viability of his gut by the methods in Section 10.5. If gut is not viable, resect it.
TEARS IN THE MESENTERY
To avoid the danger of internal hernias, close all tears by the method in Fig. 66-16. Take great care to avoid blood vessels, especially those close to the border of the gut.
If a tear is close to the gut, parallel to it, and more than 3 or 4 cm long, resect the neighbouring gut.
If part of the gut looks non-viable, resect it.
If you are in doubt about the viability of a piece of gut, make a shallow incision through its antimesenteric border, opposite the centre of the tear. If it bleeds actively, it is viable, so control bleeding and leave it. If it does not bleed, resect it.
CAUTION ! (1) Don't clamp, or tie off, or include in your sutures, any vessels which might impair the blood supply to the gut. (2) Don't try to bunch the mesentery together to tie it.
HAEMATOMAS OF THE MESENTERY
There are two common sites, the mesentery of the small gut and that of the sigmoid colon.
IN THE MESENTERY OF THE SMALL GUT, management depends on whether or not the haematoma shows signs of spreading.
If the injury was several hours ago, and the haematoma has well defined edges, and looks as if it is not going to spread, leave it alone. If the haematoma shows any sign of spreading, control bleeding by pinching the bleeding vessel between your finger and thumb. Open the haematoma, remove the clot, and swab it free of blood with a swab. Then momentarily release your finger and thumb, and find and tie the bleeding vessel.
If a haematoma bleeds and the gut is viable, insert some haemostatic sutures and wait 10 minutes. If it is still viable when you return, leave it. If it is not, resect it.
If the gut is not viable, resect it.
IN THE MESENTERY OF THE SIGMOID COLON, large haematomas are common after fractures of the pelvis. Sometimes the pelvic cavity is obliterated by bulging peritoneum filled with clot. Leave a haematoma unless it pulsates and enlarges showing that a major artery is torn and needs tying or repairing.
DIFFICULTIES WITH A GUT INJURY
If a patient BLEEDS PER RECTUM postoperatively, watch him. All patients with a gut injury pass some blood in their stools. If he has no signs of peritonitis, there is probably no need to reoperate. But, if bleeding is continuous or signs of peritonitis develop, do another laparotomy.
Large gut injuries
Most injuries of the large gut are caused by penetrating wounds, but blunt injuries can also damage it. These injuries are particularly difficult to treat, because: (1) The peritonitis which follows them is more serious than that which follows injuries to the small gut. Caecal peritonitis is particularly deadly. Even a small suture line can leak, and its consequences are only partly prevented by a drain. (2) Retroperitoneal infection from the ascending and descending colon is at least as dangerous as peritonitis. (3) There may be a large area of bruising around the tear, especially if this is caused by a high veolocity missile. (4) The patient's gut will not have been prepared for anastomosis. (5) He will probably have a haemoperitoneum which can readily become infected. All these factors make end-to-end anatomosis particularly dangerous. For, all these reasons it is a good principle never to suture and close any but the smallest wounds of the large gut.
Ifyou are not experienced, aim to: (1) Bring the wound outside the patient's abdomen as a loop colostomy, as described in Section 9.5. Or, (2) resect the injury and bring the ends of his gut out as a double barrelled colostomy. How best you can do this depends on how mobile the particular part of his injured large gut is. T=.•o other factors are also important. (a) How large his injury is. (b) How old it is. Operate early, if possible within three hours. The larger and older the wound, the more important is it to exteriorize it. Later, when he has recovered, you can refer him to have his colostomy closed, or close it yourself. The closure of a colostomy is a major procedure and carries the risk of any large gut anastomosis. Refer him if you can.
If you are experienced, and his right colon is injured, you have the option of doing a right hemicolectomy and an end-to-side anastomosis, as in Fig. 9-7. Leaking ileal contents are less dangerous than those of the large gut, so a skillful ileocaecal anastomosis is acceptable. It is a good principle in all colonic surgery to dilate the patient's anus by Lord's procedure (21.5). This will help faeces to trickle out of it, instead of building up at the suture line, and threatening the anastomosis. His sphincters will recover in a few days, by which tirne the tear should have healed.
TRY TO BRING INJURED LARGE GUT OUTSIDE THE ABDOMEN
INJURIES OF THE LARGE GUT For the earliest steps see Section 66.3. Be sure to give the patient the perioperative antibiotics described in that section.
If there is an obvious wound in his large gut, cobble it un temporarily, or clamp it, before doing anything else, to prevent faeces spilling. Cover the wound with a pack. If there is no obvious wound, start with his caecum and check the whole of his colon for tears, perforations, bruises, and blow outs. If a bullet or small missile fragment is responsible, look for tiny perforations which may be obscured by omentum.
If he has a bullet wound of his large gut, avoid suturing it if you can; the surrounding tissues are injured and the wound will break down. If you do decide to suture it, be sure to do a proximal colostomy.
CAUTION ! (1) Where possible, avoid bringing a colostomy out through his laparotomy wound, or it will probably become infected. (2) Try to avoid contaminating his laparotomy wound, or any missile wound, with faeces from his colostomy. (3) Beware of retroperitoneal bruises, because they may indicate hidden wounds. If necessary, mobilize his ascending or descending colon and look behind them. (3) Always complete the operation by doing Lord's procedure.
LORD'S PROCEDURE Do this in all cases. Dilate the patient's rectal sphincters so much by Lords procedure (21.5) that they are paralysed. They will recover in a few days, by which time the tear should have healed.
Injuries of the caecum
These are particularly difficult beca,zse the contents of a patient's caecum are fluid, leak easily, and irritate his skin, so you cannot make a surface caecostomy as if it were a colostomy. A proximal defunctioning caecostomy is also impractical. The alternatives are: (1) To insert a caecostomy tube into his caecum to prevent soiling of his skin, as in A, Fig. 66-18. This is useful for small bullet wounds and stab wounds of the caecum, but it will not defunction the rest of his large gut. (2) A right hemicolectomy, with an ileostomy and colostomy, if you are less skilled (as in C, Fig. 66-19), or with an end-to-side anastomosis (as in D in this figure), or with a side-to-side anastomosis (terminal ileum to transverse colon), if you are more skilled. Don't try to exteriorize the caecum. If a caecostomy is impractical, a right hemicolectomy will be safer. The method below tells you how to make a caecostomy with a large de Pezzer catheter which is easier to manage than a Paul's tube. This is held in place with inverting purse string sutures, after which the caecum is anchored to the abdominal wall (Stamm's procedure).
CAECOSTOMY
INDICATIONS An injury of the caecum which leaves most of it intact.
METHOD if possible, make the caecostomy in the original wound in the patient's caecum. Otherwise, close this with two layers of sutures, and make a fresh incision for the caecostomy. Apply a curved non-crushing clamp to prevent the contents of the patient's gut coming out of the hole, and cover this with a swab. Clamp a large self-retaining de Pezzer catheter, and insert this into the hole. Apply a purse string of 2/0 catgut round the catheter, and tie it, making sure that the bowel wall inverts around it as in Fig. 66-18. Tie the purse string, and then put another one round it (C, and D). Now make a small hole in the patient's abdominal wall, just big enough to take the catheter. Make it over the place where his caecum will lie comfortably when his abdomen is closed. Push long artery forceps through this hole, right up to their handles, from outside inwards (D). They will make a useful retractor. Put 4 or 5 sutures in the peritoneum round the abdominal hole, and in the peritoneum on his caecum round the caecostomy. For the moment, leave these sutures loose. Grasp the end of the de Pezzer catheter with the forceps, and pull it through his abdominal wall. Now tighten the sutures, so as to anchor the caecostomy to his abdominal wall (E). Spigot the caecostomy, close his abdominal wall, and leave his skin for delayed primary suture (9.7).
POSTOPERATIVELY Join the de Pezzer catheter by a wide bore connector to a large tube which drains into a bottle of disinfectant beside the patient's bed. After 36 hours do a gentle washout through the tube. Repeat this frequently thereafter. As soon as he is well and has good bowel sounds, you can spigot the tube, so that he can walk about. Leave the caecostomy tube in place for 3 weeks.
REMOVING THE TUBE Premedicate him. Tell him you are going to remove it on the count " . .three". Place a swab round its base where it enters his skin. Hold the end of tube firmly i n one hand and its base and his skin in the other. Then, count "One, two, three!" and firmly pull out the tube. His caescostomy will heal spontaneously.
Injuries of the right colon from the caecum to the hepatic flexure
The usual options are a right hemicolectomy or exteriorization. A hemicolectomy is best. If you don't feel capable of doing an anastomosis, you can bring the ends of the patient's gut out as an ileostomy and a mucous colostomy.
INJURIES OF THE RIGHT COLON BEYOND THE CAECUM
If the wound is in the anterior wall only, you may be able to insert a large de Pezzer catheter, as for a caecostomy, as in A, Fig. 66-19.
If the wound is less than 2 cm, and its excised edges have a good blood supply, suture it in two layers and drain the paracolic gutter. Do a proximal caecostomy with a de Pezzer catheter (B).
If the wound cannot safely be sutured do a right hemicolectomy (as described below). If you are skilled, do an end to side anastomosis (D). If you are less skilled, bring the ileum and the transverse colon out of the wound (C). An easier but less satisfactory alternative is to mobilize the peritoneum in the paracolic gutter, so as to bring the damaged part of the colon out through an appropriate incision in the abdominal wall without tension or torsion. You can then close the abdominal wound, and refect the injured colon to leave a double barrelled colostomy (E).
HEMICOLECTOMY FOR AN INJURY OF THE RIGHT COLON
Wall off the patient's intestines with gauze or place them in a sterile plastic bag. Expose his caecum. Incise the peritoneum in his right paracolic gutter close to his colon, from the tip of his caecum upwards to his right hepatic flexure (A, in Fig. 66-20). There will be little bleeding. Divide his hepatocolic ligament and tie the small blood vessels in it. Using finger dissection reflect his right colon medially (B). Cover the raw surface that remains with moist packs.
CAUTION ! Don't injure: (1) His right ureter. (2) The second or third parts of his duodenum (C). Clamp and divide the mesentery of his colon just distal to his hepatic flexure (D). Tie the branches of his ileocolic and right colic, and some of the terminal branches of his middle colic arteries. You are not operating for malignancy, so you can conveniently tie them fairly near the gut. Dissect his greater omentum off the proximal part of his transverse colon. Prepare his terminal ileum at its mesenteric border, and divide its mesentery to join the incision that you have just made in his mesocolon. Doubly tie any vessels you cut i n his mesentery. Place a pair of crushing clamps obliquely across his ileum, 1 cm from its mesenteric border. Place a pair of crushing clamps across his colon, divide it between these clamps, and remove his right colon complete with its far. shaped piece of mesentery and the piece of his terminal ileum. Cover the end of his ileum with a saline pack until you are ready to anastomose it. Close the end of his colon with continuous catgut on a straight or curved needle by passing the sutures over the end of the crushing clamp (E). Remove the clamp and pull the sutures tight. Use 2J0 atraumatic silk or chromic catgut (if infection is present) to place a continuous line of Halstead mattress sutures 1 cm from the suture line, taking care not to include any fat (F). Invert the first line of sutures as you pull these mattress sutures up.
END-TO-SIDE ANASTOMOSIS Bring the patient's ileum, still held in its clamp, close to the anterior tenia of his colon (G). I f you have not previously excised his omentum, retract it upwards, and grasp the anterior taenia of his colon with Babcock forceps at the proposed site of the anastomosis. Apply a small straight crushing clamp to the anterior tenia, so as to include a small bite of colon (H). Arrange the clamps so that you can join the serosa of his colon and the ileum with mattress sutures of 2/0 silk (I). Leave the sutures at either end long to act as stay sutures. Cut into his colon by excising the protrusion from the crushing clamp on the anterior taenia (J). Apply an enterostomy clamp behind each crushing clamp, remove the crushing clamps, and excise the crushed edges of both his ileum and his colon. If necessary, enlarge the opening in his colon. Approximate the mucosal surfaces of both organs with continuous fine catgut, starting in the midline posteriorly and continuing round on either side (K). Continue the sutures round the angles and anteriorly as Connel inverted sutures (L). Complete the anastomosis with an anterior row of mattress sutures (M). Reinforce the angles with some additional mattress sutures. Suture the edges of the mesentery of his ileum and colon, so that his intestine cannot later herniate through it.
CAUTION ! Test the patency of the stoma, it should be big enough to admit your index finger.
POSTOPERATIVE CARE Continue nasogastric suction and intravenous fluids for 3 to 5 days. Don't remove his naogastric tube until there is clear evidence that the stoma is patent, as shown by the absence of abdominal distension after the tube has been clamped for at least 12 hours.
Injuries from the hepatic flexure to the rectum
There are three possibilities: (1) If the wound involves part of the circumference of the gut, you can make a loop colostomy without dividing the gut, as in E, Fig. 66-21. Loop colostomies are easier in the transverse or sigmoid colon. But if you mobilise the colon properly you can use them anywhere at or beyond the hepatic flexure. The loop must lie easily on the abdominal wall without tension. If it is tight, it will gradually retract and cause great problems with abdominal wall abscesses. (2) If you have to resect a short (5 cm) length of gut you can bring the cut ends out through same incision (F). (3) If you have to resect a longer length of gut (more than about 5 cm), you cannot bring the two cut ends out of the same incision. So you will have to bring them out through separate incisions as faecal and mucous colostomies (G). If the lower end of the gut is too short to bring out to the surface, you will have to use Hartmann's procedure (H). To make a colostomy, goto Section 9.5.
INJURIES OF THE TRANSVERSE, DESCENDING, AND SIGMOID COLON
If the patient has a short, clean-cut stab wound, suture it, drain it, and watch him closely. A good procedure for a single small wound is to close it, and to do a loop colostomy, incorporating the suture line in the part which is exteriorized. Don't open the colostomy. I f the suture line heals, replace his gut in his peritoneal cavity. If it leaks, no harm is done. If the wound involves only part of the circumference of his gut, make a loop colostomy (E in Fig. 66-21). If it involves the whole circumference of his gut, make a double colostomy (F). If the resected segment is short, bring the two ends out through the same incision as a double colostomy (F). If the resected segment is long, bring them out through separate incisions as faecal and mucous colostomies (G). These can if necessary be far apart, because the cut ends of the gut can easily be joined up subsequently. If the distal end is too short to bring out to abdominal wall, close it in two layers and drop it back into the pelvis (H). This is Hartman's procedure as described for sigmoid vo!vulus (10.10).
LOOP COLOSTOMY varies slightly according to the site. For details, see Section 9.5.
If the wound is in the patient's descending colon, divide the peritoneum of his lateral paracolic gutter, and mobilize bluntly behind his colon, which will come away up to the surface. This will also allow you to inspect its retroperitoneal surface. If the wound is of moderate size, close it in layers transverse to the axis of his gut, and make a loop colostomy in his transverse colon proximally. Make a separate incision for the colostomy a reasonable distance away from his iliac spines.
If he has several wounds, bring out the most proximal one as a colostomy. Excise the more distal ones back to healthy, bleeding tissue. Either bring the distal end out as a mucous fistula, cr do Hartman's procedure.
CAUTION ! (1) If his peritoneum has been contaminated with faeces, put a drain through a stab wound in his flank. (2) Do Lord's procedure (21.5).
TO CLOSE THE COLOSTOMY wait several weeks until he is well and cheerful. If his gut needs reanastomosis, refer him; if it merely needs closing, you may be able to do this as in Section 9.5.
Injuries of the rectum
A patient's rectum can be harmed by injuries which reach it from his abdomen or from his buttock. An abdominal wound of the rectum inevitably involves the peritoneum. A buttock wound may involve only his perirectal tissues, or it may enter his peritoneal cavity. His bladder, his urethra, his pelvis, his sacrum, and sometimes even the lower end of his subarachnoid space can be injured at the same time. The main danger is that faeces will leak into the tissue round his rectum and infect it, perhaps fatally. You cannot bring wounds of a patient's rectum and rectosigmoid outside his abdominal wall as you can elsewhere in his colon. So aim to: (1) Divert faeces from his rectum by doing a diversionary colostomy above it. This is much safer than merely inserting a large rectal tube. (2) Empty his gut beyond the colostomy. (3) Drain the wound. The main distinction is between wounds which involve his peritoneum, and those which do not. Intraperitoneal wounds should be managed like wounds of the distal colon. Make a left iliac colostomy, close the rectal wound, and drain it. Extraperitoneal wounds make an opening from a patient's rectum into the tissues round it below the reflection of the peritoneum. There are problems: (1) Diagnosis can be difficult, as in the patient JANE described below. (2) Other structures, especially the bladder and the pelvis, are often injured too. (3) The rectum is difficult to expose from below, so expose it from above, and make a drainage incision down from above, into the peritoneum.
JANE (5) fell from a tree on to a dead branch. Later, she complained of vague tower abdominal pain. There was a little blood in her rectum. She was examined under anaesthesia. A probe entered a wound in her rectal wall and tracked far upwards. Exploration showed that a twig had passed behind her peritoneum lateral to her rectum, in front of her right common iliac vessels, avoiding her right ureter, and up alongside her inferior vena cava as high as her right kidney. Fortunately, no vital organs were damaged. A temporary defunctioning colostomy was done and she recovered.
JAKE (24), a performer in a disco bar, jumped in the air and fell on his microphone stand, injuring his perineum. Accompanied by much singing, he was brought irr laughing by his friends. His fresh minor looking perineal wound was toileted and closed by immediate rimary suture. Although he had no abdominal signs, the cautious house officer admitted him. The next morning his pulse rate had a risen (a very important sign). Later in the day he became very ill with a high fever and signs suggesting peritonitis in his lower abdomen. Laparotomy showed a 10 cm wound in his perineum. This led to an area of severe cellulitis, but had not injured any viscera. Large doses of broad spectrum antibiotics cured him. LESSONS: (1) Wounds in some parts of the body can be closed, if you see them early enough. In other areas, including the perineum, this is very dangerous. (2) Wounds may be deeper than they seem, and need radical toileting.
WHENEVER THE RECTUM IS INJURED DO A DEFUNCTIONING COLOSTOMY
INJURIES OF THE RECTUM
EXAMINATION If a patient might possibly have a rectal injury, study the wound track carefully. Put him into the lithotomy position and examine him with your finger and with a sigmoidoscope. if necessary, examine his rectum under anaesthesia. Is his anal sphincter torn? Does the injury involve the urethra or vagina? (68.3). Carefully examine the patient's abdomen for signs of peritonitis (6.2). if necessary, take an erect film and look for gas under his diaphragm (66-4).
PERIOPERATIVE ANTIBIOTICS in all but the most trivial rectal injuries, antibiotic protection is critical, particularly protection against anaerobes (2.7). The patient will need intravenous metronidazole 7.5 mg/kg 8 hourly, for 3 or 4 days before switching to the oral route. Combine this with chloramphenicol, gentamicin, or co-trimoxazole.
INTRAPERITONEAL INJURIES OF THE RECTUM
Make a lower midline incision. Control haemorrhage. This can be severe, and you may very occasionally even have to tie the patient's iliac arteries on both sides. If so, watch his ureters. Wash out his peritoneal cavity to get it absolutely clean (6.2). Squeeze out any faeces in his rectum into the normal bowel above the lesion, or wash them downwards. Excise the edges of the perforation.
If the patient's rectal wound is small, suture it, and insert a large rectal tube.
I f his rectal wound is large, do a defunctioning colostomy (9.5). Make this as close to the injury as possible. The most convenient place is likely to be his sigmoid or transverse colon. The more worried you are about closure, the more i mportant it is for the colostomy to be fully defunctioning. I nsert a drain down to the site of the repair. If his injury is really severe, you may have to resect a length of rectum or rectosigmoid, do a terminal colostomy, and close the blind end of his rectum as for Hartman's procedure (10.10). Do Lord's procedure (21.5).
EXPERITONEAL INJURIES OF THE RECTUM
Do a laparotomy (66.3). Excise the wound track from the patient's perineum. Clean out his perirectal space from above. Incise his pelvic peritoneum on each side of his abdominal rectum. If necessary, use blunt dissection with your fingers to peel his prostate and seminal vesicles off the front of his rectum. Remove all foreign bodies, pieces of clothing, etc. Make sure his wound is clean. If possible try to stitch up: (1) his rectum using inverted sutures, (2) his anal sphincter. Make a double defunctioning colostomy, preferably with his sigmoid colon. Wash out all faeces below the colostomy. incise the skin obliquely beside his coccyx. Using a pair of artery forceps, open up a track from his rectovesical pouch to your skin incision. Bring down a large corrugated rubber drain.
POSTOPERATIVE CARE (both kinds of injury) Wait several weeks before referring him for the closure of his colostomy (9.6).
DIFFICULTIES WITH RECTAL INJURIES
If a patient shows SIGNS OF PERITONITIS, do an i mmediate laparotomy. Put him into the Trendelenberg position, and examine his abdominal cavity through a low midline or paramedian incision. Examine his pelvic viscera.
If his BLADDER HAS RUPTURED INTRAPERITONEALLY, repair it (68.2).
If his URETHRA MIGHT HAVE BEEN INJURED, explore the wound to make sure. If it is normal leave it. If it has been injured, drain his bladder through a suprapubic catheter, and treat him as in Section 68.3.
If digital examination of his rectum shows an injury which FEELS LIKE A TEAR, but he has no signs of peritonitis, assume that he has an extraperitoneal penetrating injury. Drain his pararectal tissues, and do a sigmoid colostomy. Don't try to suture his rectum.
If his ANAL SPHINCTER IS PARTLY TORN, but his anorectal ring feels intact, toilet and drain his wound.
If his ANAL SPHINCTER IS COMPLETELY TORN across (rare), don't try primary repair, unless the wound is clean cut. Better, do a colostomy, toilet his peritoneal wound, and refer him for a definitive repair later.
Duodenal injuries
If a patient hits the steering wheel of his car, he can crush both his duodenum and his pancreas against his spine . The combination of a leaking duodenum and traumatic pancreatitis usually kills him. Diagnosis and treatment are difficult, and may be delayed for days because both organs lie at the back of his abdomen behind his peritoneum. These injuries are difficult even for the most skilled surgeon, and you will have to manage the patient as best you can. Fortunately, injuries of the duodenum are rare. The patient's injured duodenum leaks into his peritoneal cavity or behind it and causes a deep seated pain in his epigastrium and back, which gets steadily worse. This is accompanied by severe vomiting, fever, toxaemia, and sometimes by shock. His epigastrium becomes tender, silent, and a little distended. When you open it, you find an oedematous red mass behind his stomach. The tear itself is difficult to find, and you may need to lift his duodenum and pancreas forwards from the right ( Kocher's manoeuvre). You should be able to suture small tears into the peritoneal cavity, and some of the tears behind it. If you cannot do this, the unsatisfactory alternatives are: (1) A duodeno jejunostomy, which is difficult, (2) a gastroenterostomy which does not divert bile from the wound, or (3) a Foley catheter which does not provide enough drainage.
INJURIES OF THE DUODENUM
At laparotomy you find a large oedematous mass at the back of the patient's upper abdomen, displacing his hepatic flexure downwards to the left. Find the triangle of peritoneal tissue which lies, with its apex pointing medially, between his colon and his duodenum. Explore any haematoma at the base of his mesocolon, or over the convexity of the second part of his duodenum. Divide the bloodless fold of peritoneum above and lateral to the hepatic flexure of his colon. Draw this downwards and medially; if necessary, use a sponge stick. You should now see his duodenum, except for its distal part underneath his mesenteric vessels. I f there is no injury on the front of his duodenum, move to the left side of the table. Incise the peritoneum lateral to the second part of his duodenum. Put your hand under it and under the head of his pancreas, and reflect them forwards. Look for staining with bile and blood, and dissect gently to reveal the tear. This is usually in its second or third parts. Look carefully at the last part of the patient's duodenum, and at his duodeno-jejunal flexure. if necessary, reflect the peritoneum off it with blunt-tipped scissors.
BRUISING OF THE DUODENUM Don't try to suture a bruised duodenum. Instead, leave it and insert a drain.
A SMALL TEAR OF THE DUODENUM Suture this with nonabsorbable sutures as a single layer. If it is longitudinal, don't try to sew it up transversely. Stitch omentum over the tear and drain the area for several days.
A LARGE TEAR OF THE DUODENUM If the tear is too large or too ragged to suture, there are three possibilities:
If you are skilled, you can close the hole by bringing a loop of gut up onto it, so as to make a duodeno-jejunostomy.
If you are less skilled, repair the tear, and do a gastroenterostomy.
Alternatively, drain the patient's duodenum through a large bore Foley catheter, with two extra holes cut near its tip. Pass i t down into the tear. Partly inflate the balloon, to keep it in place. Bring it out through a stab wound in his flank to provide dependent drainage. if possible, apply continuous suction. Drain the retroperitoneal area. Two weeks later deflate the balloon, and slowly withdraw it over several days. The fistula will usually dry up within a month. If stenosis develops, the patient will need a feeding jejunostomy.
COMPLETE TRANSECTION AT THE DUODENO-JEJUNAL FLEXURE You may be able to do an end-to-end anastomosis. If the anastomosis breaks down, it will at least convert the leak into a fistula instead of a spreading peritonitis.
DRAINS The suture line may leak, so always insert a drain through a separate stab wound in the patient's right flank.
POSTOPERATIVE CARE For all lesions do a feeding jejunostomy (9.6a), except when you have already done a gastroenterostomy. You will have to feed the patient through his injured duodenum. The ileus that follows duodenal lesions can last for several weeks.
Pancreatic injuries
These injuries range from mild bruising to a pancreas which has been cut vertically in half. The patient may have few physical signs until a spreading retroperitoneal abscess develops. If his pancreas is only bruised, you can drain it. This can be life-saving. A pancreatic fistula will probably form, but it can be treated after he has recovered from his acute injury. Pancreatectomy is the treatment of choice for major injuries. This is difficult, so close his abdomen and if possible refer him rapidly. The only exception is an injury to the tip of the tail of the pancreas.
THE PANCREAS
At laparotomy you find that the peritoneum over an injured patient's pancreas is discoloured and oedematous; sometimes with yellow opaque areas of fat necrosis. Open his lesser sac by detaching his greater omentum from his transverse colon. Reflect his stomach upwards, and his transverse colon downwards, to expose his pancreas.
If his pancreas is only bruised, insert a drain and close his abdomen.
If there is a tear in the surface of his pancreas, suture it.
If the tail of his pancreas has been torn off, remove it, cut i t across in a fish tail incision, find the end of the duct, and tie this with a nonabsorbable suture. Then join the two ends of the fish tail, using nonabsorbable sutures through its capsule. Drain the area.
If his pancreas is hopelessly torn, insert a drain and close his abdomen.
Injuries of the gall bladder
If only the fundus of the gall bladder is injured, do a cholerystostomy (13.3). With severe injuries the best treatment is usually cholecystectomy, which is difficult (13.6). You can do a cholerystostomy with a de Pezzei catheter in much the same way as a caecostomy.
CHOLECYSTOSTOMY Put a de Pezzer catheter into the patient's gall bladder as in Figs. 13-1 and 66-18. Anchor it to his abdominal wall in a similar way. If you find any stones in his gall bladder, remove as may as you can, before closing the purse string suture round the tube. A temporary biliary fistula will form, and then slowly heal.
Other difficulties with abdominal injuries
There are many of these. They include the patient who is brought in late, the patient whose injured abdomen or abdominal wall becomes infected, the development of a fistula, or the collapse of a lung.
DIFFICULTIES WITH AN ABDOMINAL INJURY
If a PATIENT IS BROUGHT IN LATE, more than 18 hours after an injury, manage him like this: If he looks well, feels well, his temperature is normal, he has no signs of peritonitis or abscess formation, and if the site of his wound is only minimally tender, a laparotomy may not be necessary. None of his viscera may have been perforated, or the perforations may have sealed themselves off. Watch him, and if he deteriorates, operate. If his condition is not good, but he looks as if he could withstand an operation, operate. If he is in severe shock, resuscitate him. Give him intravenous fluids, and antibiotics. Pass a nasogastric tube. He will probably die anyway, but give him a chance. Operate, unless he clearly has only minutes to live. If you refer him, resuscitate him first
If a patient's PULSE RATE RISES POSTOPERATIVELY, and his abdomen becomes increasingly tender and rigid, there is sepsis inside it. After an abdominal injury a patient is in danger from: (1) Generalized peritonitis (6.2). (2) Subphrenic (6.4) or other abdominal abscesses (6.3). (3) Retroperitoneal abscesses. Treat peritonitis as in Section 6.2. Prevent it by: (1) closing lacerations in a patient's small gut carefully, (2) managing injuries to his large gut as in Section 66.11, (3) inserting drains appropriately, (4) cleaning out his injured peritoneum with saline before you close it, and (5) using perioperative antibiotics as in Section 2.7.
If a FISTULA forms, treat it as in Section 9.14. Sometimes you cannot avoid one, so prepare for one deliberately: (1) After a bladder injury do a suprapubic cystostomy (22.6 and 22.7). (2) After pancreatic or duodenal injuries, insert a drain. (3) When the large gut has been injured, do a colostomy (9.5).
If his ABDOMINAL WOUND BECOMES INFECTED and sloughs, lay it open, treat him with antibiotics, hypochlorite ('Eusol') dressings, and delayed skin grafting. This may happen when: (1) His unprepared colon or ileum has been opened. (2) There has been major trauma. (3) Much blood has been lost. (4) Perioperative antibiotics have not been given, or have not been properly timed. Delayed suture of the abdominal wall will make infection less likely.
I f parts of a patient's LUNG COLLAPSE, or an entire lung collapses, treat him as in Sections 9.9 and 9.10. Prevent lung complications after any laparotomy by early breathing exercises. Occasionally, you may need to slap his chest, or bronchoscope him to remove mucus plugs. Very rarely, you may need to do a tracheotomy, or to ventilate him artificially. This i s one of the complications of any operation under general anaesthesia. It is more common after an abdominal injury because: (1) His chest may have been injured at the same time. (2) Major abdominal wounds make breathing difficult.
