Medical Science Publication No. 4, Volume 1
REPARATIVE SURGERY (SECONDARY SURGERY) IN THE KOREAN CAMPAIGN*
COLONEL FRANK E. HAGMAN,MC
The management of battle casualties during the Korean conflict, as inWorld War II, was in phases and conformed, in general, with military echelonsand geographic deployment of military forces. This discussion will be limitedalmost entirely to certain aspects of reparative surgery which pertainedto the Korean conflict.
The place reparative surgery had in combat may become clear from a briefexamination of the four main phases in managing casualties. This conceptwas developed in World War II and used successfully in the recent conflict.
1. Medical Aid Measures. These measures were the first phaseof management. They were administered within division areas and directedprincipally toward providing the most competent and urgent care in preparationfor the second phase.
2. Initial Wound Surgery. This phase was performed usually inforward surgical hospitals. Initial wound surgery provided the first orderlyand definitive surgical treatment of wounds. Under adverse combat conditionsinitial surgery necessarily was limited in scope.
3. Reparative Surgery. This phase, usually performed in Japan,continued surgical care to completion, beginning where initial surgeryleft off.
4. Reconstructive Surgery. This phase usually was accomplishedin the Zone of Interior. It was the final stage of management for casualtieswith injuries of such magnitude as to preclude return to duty within thetime limit set by the Far East Command.
During the Korean campaign reparative surgery was carried out largelyin hospitals in Japan and as in World War II (1) had these objectives:
1. To shorten the period of wound healing.
2. To prevent and eradicate wound infection.
3. To restore function.
*Presented 23 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
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4. To return patients to duty.
5. As rapidly and safely as possible, to evacuate patients to the Zoneof Interior when restoration to duty could not be expected within a reasonabletime.
For the purpose of providing the best available care during the reparativephase of surgery, specialized treatment services in hospitals in Japanwere organized for casualties inflicted with neurosurgical, thoracic, eyeand cold injuries. In addition, efficient centers were provided for treatmentof infectious hepatitis and for patients in the convalescence stage followinginjury or illness who required a period of reconditioning before returnto duty.
The support given by personnel and hospitals in Japan to the managementof battle casualties stemming from the Korean campaign was supremely andvitally important. On many occasions, because of the tactical situationin Korea, the first definitive surgical care was given in Japan. Moreover,the hospitals in Japan gave magnificient support to casualties with complicationseither overlooked in forward hospitals or developing inevitably duringthe patient's course.
Delayed Closure of Wounds
In the Korean campaign primary suture of war wounds in general was neitheradvocated nor practiced. Based upon experience of World War II (2),wounds were left open after initial surgery. Cranial, cerebral and maxillofacialwounds were exceptions to the policy as also were wounds associated withopen injuries of the chest, with abdominal evisceration and with majorjoints. It soon became apparent that primary suture was unwise for thevast majority of casualties. Despite previous experience, primary suturewas performed occasionally. Complications resulting from such practiceoccurred more often than necessary and were further convincing evidenceagainst primary suture.
Delayed suture of war wounds, therefore, was necessary for most battlecasualties subjected to initial surgery in Korea. Delayed closure of woundsconstituted a large part of the reparative phase of surgery in Japan. Itbecame a routine procedure, not very stimulating to surgeons interestedin more exotic operations. Still it was of great importance to preventundue cicatrization and production of granulation, obliterating anatomicallayers; to prevent the hazards of cross-contamination from bacteria indigenousto the hospital and frequently resistant to available antibiotic and chemotherapeuticagents; and to hasten wound healing and lessen deformity and disability(2). Successful delayed closure in large measure depended
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upon the interest of the surgeon (3) and painstaking attentionto many details, among which were-
1. Period of nontransportability, during which casualties were not sentelsewhere. Immobilization of the region, surgically repaired, was frequentlyof prime importance.
2. Thorough débridement prior to closure. Well débridedwounds could be repaired early.
3. Repairing wounds within 4 to 6 days when possible, using appearanceof wound rather than length of time as the governing factor.
4. Proper preparation of wounds not ready for repair.
5. Strict avoidance of tension for approximation of tissues.
6. Adequate drainage, preferably through a small separate stab wound.
7. Gentleness in handling tissues.
8. Fine suture material.
9. Culture and sensitivity studies of bacterial flora when failure occurred.
Secondary Hemmorhage
During the Korean campaign war wounds were often complicated by secondaryhemorrhage (4) occurring on the average of 15 days after inception.Although hemorrhage was sometimes venous in origin, usually it ensued afterarterial injury, more often associated with rupture of traumatic aneurysmthan arteriovenous fistula and more apt to occur in infected than relativelyclean wounds. Bleeding occurred unheralded, was alarming and even exsanguinating.Vascular injuries were overlooked at times and became apparent only whensymptoms and signs pointed to the presence of traumatic aneurysm, arteriovenousfistula or when tempestuous hemorrhage suddenly supervened. Aneurysms andarteriovenous fistulae were managed conservatively when major vessels wereinvolved and no serious or impending complications became apparent. Itwas the policy in the Far East Command to return such patients to the Zoneof Interior. Operations were performed for indications such as the following:
1. Manifest internal or external hemorrhage.
2. Sudden increase in swelling or size of a lesion.
3. Sudden increase in pain when probably associated with vascular injury.
4. Imminent rupture of pulsating mass.
5. Increased swelling of extremity associated with a wound, with impairedcirculation and probably not associated with phlebitis per se.
Surgical principles considered of importance were-
1. Adequate blood volume replacement.
2. Tourniquet control when possible.
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3. Long properly placed incision.
4. Proximal and, when possible, distal control of artery before surgicallyattacking injured area.
5. Repair of injured artery when large and important, by suture of defectin its wall, by end-to-end anastomosis or by grafts if necessary (usuallyvein such as great saphenous).
Neurosurgical Casualties
The management of neurosurgical casualties during the early months ofthe conflict was a distressing problem, replete with difficulties. Thesedifficulties stemmed from lack of sufficient neurosurgically trained personnel,inability to hold neurosurgical casualties in Korea, pressure of largenumbers of other types of casualties, relative inexperience of generalsurgeons and the uncertainties pertaining to the Korean conflict. Duringthe first months of the campaign, initial craniocerebral surgery was attemptedin Korea and Japan by general surgeons. The incidence of complicationssuch as acute and subacute cerebritis and frank brain abcess was reportedto be 42 percent (5).
While a neurosurgical service was established in an Army Hospital inJapan soon after hostilities began, it was not until mid September 1950that this service was headed by a board-certified neurosurgeon. EventuallyArmy neurosurgical casualties were sent to this service which was keptinordinately busy treating complications. It was not possible until February1951 to place an Army neurosurgical team in Korea composed of partiallyneurosurgically trained medical officers under the supervision of the soleboard-certified Army neurosurgeon assigned to the Far East Command. Thereported incidence of craniocerebral complications gradually dropped toabout 4 percent (5). In the meantime (and subsequently) a numberof neurosurgical casualties were successfully treated by neurosurgeonsassigned to U. S. Navy hospitals and hospital ships, including the Danishhospital ship "Jutlandia."
At least three experienced Army neurosurgeons could have been very usefullyemployed from the onset of the military effort. Should another conflictoccur without warning, cognizance should be taken of this unfortunate experienceof insufficient professional personnel for the management of neurosurgicalcasualties. It seems apparent that the military establishment should havewithin the regular corps or in reserve, neurosurgeons who could be dependedupon to extend adequate support to the Armed Services much more quicklythan was the case in Korea.
The volume of the reparative phase of craniocerebral surgery was reducedgreatly by improvement of initial surgery. Some of the factors during initialsurgery leading to improvement were-
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1. Débridement of all layers of the scalp.
2. Excision, en bloc, of involved bone.
3. Débridement of dura.
4. Resection of all necrotic brain tissue.
5. Removal of all indriven bone fragments.
6. Closure of dura, by facial grafts if necessary.
7. Removal of metallic foreign bodies when feasible (including oppositeside from missile entrance when close to cortex and associated with subduralhematoma).
Penetrating wounds of the spinal column and cord required débridementas completely as soft tissue wounds. Frequently wound care included laminectomy,removal of bone spicules, evacuation of hematoma and excision of devitalizedtissue.
Prior to establishing neurosurgical teams in Korea much of this wasdone in Japan. Patients with paraplegia or quadriplegia were managed withinfinite attention to details. Decubitus ulcer was extremely rare whilethese patients were overseas. These results were obtained by tireless,enthusiastic and sympathetic doctors, nurses and corpsmen. Patients weremanaged by periodic changes of position, employing the litter turning methodor Stryker frame; by excellent nursing attention; by overcoming and preventinganemia; by maintaining and improving nutrition; and by employing catheterrather than suprapubic bladder drainage. They were transported to the Zoneof Interior in pressurized cabin planes, on Stryker frames and under thesupervision of trained personnel.
Thoracic Injuries
In the early days of the conflict patients with complicated thoracicinjuries often were sent to the Zone of Interior because of insufficienthospital beds and personnel, circumstances beyond anyone's control at thetime.. Two Army thoracic surgical services were established and eventuallywere able to carry out reparative surgery. One service (6), forexample, from the beginning of hostilities until November 1952 (16 months)gave the following support to battle casualties with visceral chest injuries:
Total patients treated | 2,577 |
Penetrating wounds | 1,855-72 percent. |
Perforating wounds | 670-26 percent. |
Crushing injuries | 52-2 percent. |
Patients with hemothorax | 1,598 |
Remaining bacteriologically sterile | 1,182-74 percent. |
Infected | 416-26 percent. |
Chest clear after treatment | 1,262-79 percent. |
Returned to duty | 68 percent. |
Evacuation to ZI with other injuries | 32 percent. |
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During this interval 230 decortications were done on the service withthe following results:
Infected | 76 percent. |
Noninfected | 24 percent. |
Good results-duty | 91 percent. |
Fair results-limited duty | 4 percent. |
Poor results-evacuated | 5 percent. |
The optimum time for decortication was found to be between 3 and 5 weeks.If attempted too early, bleeding, edema and difficulty in locating foreignbodies were noted. Ninty-two percent of patients requiring decorticationhad had closed intercostal tube drainage for hemothorax prior to beingsent to this thoracic surgical service. While there were no doubt manyother contributing factors, this sort of experience was used to intensifyefforts in forward hospitals to treat hemopneumothorax by needle and syringeaspiration rather than by inserting intercostal tubes for drainage of hemothorax.
During this period foreign bodies were removed from the chest of 280patients. These were classified as follows:
Shell fragments removed, 1-9 cm., mostly irregular | 85 percent. |
Bullets, various caliber | 15 percent. |
Mediastinal foreign bodies | 77. |
Pericarditis with effusion | 34. |
With abcesses | 18. |
Of heart muscle | 14. |
Operation for foreign bodies was employed for missiles 1.5 cm. in diameteror greater, when they were in a dangerous location or when they demonstratedpersistent or developing reactions about them. Operation was delayed for2 to 3 weeks to permit subsidence of local reaction about foreign bodiesto lessen bleeding, facilitate locating and removing and to get patientsin best possible condition.
Patients with thoraco-abdominal wounds were usually evacuated to theZI because of complications associated with abdominal wounds. Chest injuriesassociated with neurosurgical injuries (271) were problems to manage andin paraplegics were aspirated and drained with difficulty because of position.Patients with associated orthopedic injuries (602) in the majority of instancesrequired evacuation to the Zone of Interior.
It is of more than passing interest that the overall mortality for patientson this service during the period of this report was 0.5 percent and thesurgical mortality was zero.
Maxillofacial Wounds
Reparative surgery of maxillofacial wounds was done usually by teamscomprised of a general surgeon, interested in and familiar with
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the head and neck, a dental surgeon experienced in this field, an experiencedanesthesiologist or anesthetist capable of giving nasotracheal, orotrachealor transbronchial anesthesia, and competent nurses and corpsmen (7).Nasogastric intubation was employed for feeding patients when swallowingwas difficult and for patients troubled with vomiting.
Wounds extending into the month frequently disrupted, especially whenbuccal mucosa was not sutured initially and when good mouth hygiene wasneglected. Gross infection and necrosis were treated by irrigation, antibiotics,removal of foreign bodies and loose bone spicules and loose and brokenteeth.
Fine absorbable everting mattress sutures were employed within the mouthto close the buccal cavity and cover bone. Dependent drainage was provided.Covering was furnished for avulsed jaws, lips and mucosa. Fractures weretreated by fixation employing intraoral wiring or extra-oral fixation.Postoperative irrigations were employed every 2 hours or oftener and afterintake of food. Tracheotomy was done, if not done previously, for extensiveinjuries of the tongue, larynx and neck, or when hemorrhage, infectionor edema threatened embarrassment of the air passages. Injuries of theparotid duct were repaired over a ureteral catheter employing 5-0 silksutures. Mucoperiosteal flaps were provided for injuries involving thehard palate.
Patients requiring extensive reconstructive maxillofacial surgery werereturned to the Zone of Interior. Important principles of rnaxillofacialrepair included-
1. Frequent saline irrigations.
2. Large doses of antibiotics.
3. Early débridement.
4. Conservation of skin and bone.
5. Removal of loose teeth and bone spicules.
6. Early closure of mucous membrane.
7. Dependent drainage.
8. Fixation of fractures.
9. Postoperative irrigations.
10. Tracheotomy as indicated.
11. Teamwork.
Abdominal Wounds
Experience in Korea did not change concepts of managing wounds of thelarge intestines as promulgated during World War II. Most surgeons practicedexteriorization of large bowel injuries through a
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separate muscle-splitting incision. Occasionally an individual surgeonfailed to follow this general practice, closed colonic wounds primarilyand dropped the colon back into the abdomen. In some patients nothing untowardhappened. However, too many patients so treated developed abscess, fecalfistula and increased disability to warrant primary closure despite liberaluse of whole blood, antibiotics, etc.
The difficulty with exteriorization stemmed, first, from employing laparotomywounds rather than separate muscle-splitting incisions, and second, frominadequate mobilization of the bowel at the time of exteriorization (ordefunctioning colostomy). The former increased severe infection while thelatter resulted in retraction of the colon in whole or in part back intothe abdomen. In either event the resulting difficulties provided clinicalmaterial for surgeons in Japan, complications preventable in whole or inpart at the time of initial surgery. Furthermore, rectal injuries whichhad escaped recognition initially presented problems such as fecal fistula,abscess and retroperitoneal cellulitis. Aside from revising and institutingcolostomies, surgeons were able to close many colostomies and return patientsto duty within the theater.
Efforts were directed towards repairing fistulae of the small bowelearly to prevent further depletion of nutrition, water and electrolytebalance and when closure was impracticable to short-circuit around themto accomplish the same purpose. The many and various complications involvingwounds of the abdomen were treated in accordance with sound surgical principlessupported by all available adjuvants.
Extremities
The basic concepts derived from World War II for managing injuries ofthe extremities were employed. These included an adequate period of nontransportabilityfor the casualty to provide balanced suspension and traction for reductionand alignment of fractures until union occurred, early closure of wounds,additional débridement as necessary, careful attention to nutritionaland blood deficiencies and administration of appropriate antibiotics.
Evacuation of patients to the Zone of Interior with open fractures ofmajor bones had to be done early during periods of acute shortage of facilitiesin Japan (8). When patients could be returned within 2 weeks afterwounding this practice was reported by orthopedic surgeons in the Zoneof Interior, who subsequently received and treated them, to have certainadvantages:
1. Less beds were required overseas.
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2. Patients were received early enough for definitive treatment andrequired no further movement until completely rehabilitated.
3. Slight delay did not materially increase wound infection, impairthe results of wound closure, decrease function or increase disability.
4. But there must have been absence of complications and contraindications,and transportation must have been completed within the 2-week period.
Interamedullary fixation (9) of long bones was usually reservedfor closed fractures and therefore was not employed extensively in battlecasualties. However, occasionally the method was used when débridementhad been satisfactory, permitting early closure of soft tissues, and itappeared reasonably certain that the patient could be sent to duty withinthe theater.
Convalescence Hospitals
It is abundantly clear that the foregoing discussion has dealt withonly a few highlights of reparative surgery. Before concluding, a few remarksconcerning hospitals for convalescence and rehabilitation should be made.Separate organizations were provided without elaborate treatment machinery.These units carried out dynamic, efficient, complete, and uniform programsto fill the devitalizing hiatus which existed after patients required nofurther definitive care but still were not fit for return to duty.
Convalescence hospitals in Japan served with great distinction and furnishedbrilliant backing for other hospitals during the final phase of medicalcare. The approach to patients was positive (10), aimed at rapidrestoration of function and resumption of normal physical activities. Patientssoon began to look and act like soldiers.
Many ambulatory neuropsychiatric patients were sent to convalescencehospitals direct from Korea. Under the supervision and care of psychiatriststhey participated in the reconditioning program.
All patients were placed in one of four classes in accordance with theirphysical condition after evaluation by medical officers in attendance.As rapidly as possible patients were placed into the next more active classand finally discharged to duty.
Patients were organized into military units, lived in barracks, compliedwith demands of military discipline and alternated physical activitieswith classroom work. At all times the environment of convalescence hospitalswas such that patients were encouraged to shed spurious gains of chronicinvalidism for resumption of adult obligations of normal human beings.
References
1. Technical Bulletin Med. 147. Department of the Army,22 June 1951.
2. Churchill, E. D.: Management of Wounds. Symposium onTreatment of Trauma in the Armed Forces XI, 1-5, March 1952. Army MedicalService Graduate School, Walter Reed Army Medical Center, Washington, D.C.
3. Fisher, Daniel: Secondary Closure of Wounds. The SurgeonsCircular Letter. Med. Sec. GHQ FEC SCAP and UN Vol. VI, No. 9, September1951.
4. Russell, J. P.: Symposium on Military Medicine in theFEC. Supplementary Issue, The Surgeons Circular Letter, page 66, September1951.
5. Melrosky, A. M.: Annual Report on the Management ofNeurosurgical Casualties in the FEC. The Surgeon FEC, 1951.
6. Valle, A. R.: Analysis of Chest Casualties Treatedin a General Hospital. Med. Bulletin US Army Far East, Vol. 1, No. 4: 60,March 1953.
7. Rush, J. T., and Quarantillo, E. P.: MaxillofacialInjuries. Annals of Surgery 135: 205-220, 1952.
8. Bollibaugh, O. B.: Symposium on Military Medicine inthe FEC. Surgeons Circular Letter (supplementary issue), page 66, September1951.
9. Kirkpatrick, C. L., Jefferies, V. H., Neatuska, W.H., and Radke, R. A.: Operation of Tokyo Army Hospital. Med. Bulletin USArmy FEC. Vol. 1, No. 9, 166-167, August 1953.
10. Cooch, J. W.: Experience in the Operation of a ConvalescenceHospital. Surgeons Circular Letter. Med. Sec. GHQ FEC, SCAP and UN Vol.VI, No. 11, 232-233, November 1951.
