CHAPTER XXIX
Special Types of Abdominal Injury
GordonF. Madding, M. D., and Knowles B. Lawrence, M. D.
VISCERALINJURIES WITHOUT PENETRATION OF THE PERITONEAL LAYER OF THE ABDOMINAL WALL
In 12 of the 3,154abdominal injuries observed by the 2d Auxiliary Surgical Group during 1944 and 1945,injuries of abdominalviscera occurred without penetration of the abdominal wall by the woundingmissile (table 96).
In10 of the 12 cases the missile, while it caused a through-and-through wound ofthe abdominal parietes, did not injure the peritoneum. In the 2 other cases, theforeign body was retained within the abdominal wall. The velocities of the missiles causing the through-and-through woundswere apparently greater than those of the missiles retained within theabdominal wall. It may be assumed that the additional imparted energy producedan explosive effect in the abdominal wall, and that this effect was imparted, inturn, to the intra-abdominal structures.
The fact that visceracontaining gas and liquid (that is, hollow viscera) were injured in 9 of the 12cases suggests that this type of viscus may be peculiarly prone to injury fromindirect trauma because of the transmission of the force of the missile by thevisceral contents. The fact that in one case (table 96, case 3) the cecum andascending colon were split open along the anterior longitudinal band seems tosupport this theory.
In the single fatal casein this group (table 96, case 8) the patient sustained a severe wound of theleft chest. The missile lacerated the pleural surface of the left dome of thediaphragm, with apparent indentation of the stomach wall and production of asubserosal hematoma in that area. Pulmonary damage was extensive, and theintra-abdominal injury seems to have played no significant part in thefatality, which was the result of shock and pulmonary edema.
The experience of thegroup surgeons with injuries of the abdominal wall which did not involve theperitoneal layer clearly indicates that it would have been an error to assumethat there was no intra-abdominal visceral injury merely because the missile didnot enter the peritoneal cavity. Whenever there was clinical evidence ofintraperitoneal involvement, exploration was regarded as mandatory. The visceralinjuries thus found in this series are proof of the wisdom of that policy.
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VISCERALINJURIES CAUSED BY BLUNT TRAUMA AND BLAST
Perforationor rupture of an intra-abdominal viscus, which is always a possibility in anyinstance of blunt trauma or blast, occurred in 14of the 3,154abdominal injuries in this series (0.44 percent) in theabsence of peritoneal penetration (table 97). These cases are exclusive of injuries to the bladder, urethra, and otherurogenital structures associated with fractures of the pelvis. The smallintestine, the spleen, the colon, the mesentery, and the kidney were mostfrequently injured, alone or in combination.
Nineof the fourteen injuries resulted from vehicular accidents and three from blastfrom a nearby explosion of an artillery shell. Occasionally a subcutaneoushemorrhage indicated the area of greatest trauma, but in none of these injurieswas there a skin wound. The diagnosis of possible intra?abdominal injury wasmade in 13 of the 14 cases by the history of injury and the physical findings. Tenderness wasusually present, and peristalsis was constantly absent. In the remaining case(table 97, case 14) an extensive thoracic injury overshadowed the abdominalinjury, which was not suspected until autopsy.
The casefatality rate in this group (2 deaths in 14 cases) isconsiderably lower than the rates of 44and 55 percentreported in the literature for this type of injury. The good results are attributable toearly and vigorous therapy for shock, followed by prompt surgical intervention.The series may be small, but in the majority of cases the lesions were such thatdeath would undoubtedly have occurred in the absence of surgical intervention.
PENETRATING(PERFORATING) WOUNDS OF THE ABDOMINAL WALL WITHOUT VISCERAL INJURIES
The peritonealcavity was penetrated in 41 ofthe 3,154 abdominal wounds in this series (1.3 percent) withoutsignificant damage to any of the intraperitoneal viscera.1 The wounds wereperforating in 11 of the 40 recordedcases and penetrating in the other 29. The wounding agent was listed as a high?explosive shell fragment in 33 cases and asgunshot in the other 8.
In24 of the 41 cases, the wounds were thoracoabdominal. This proportion (58.5percent) differsmaterially from the 26.2 percent of thoracoabdominal wounds in the entire seriesof 3,154 abdominal injuries, though the figures are too small to beof real significance. The right diaphragm was wounded 13 times and the left 11times. In 23 of the24 cases in this group, the missile entered the peritoneal cavity from thethorax. In 7 cases, there was a double perforation of the diaphragm, the missileeither lodging in the lung or passing out through the chest wall. In 2 of the 11single perforating wounds, the injury was produced by sharp rib fragments. Inthe 5 other cases in which
1Three similar cases in which only the omentum wasinjured are not included in these 41 cases. In 2 of the 3, smallrents in the omentum wererepaired by suture. In the third case, a segment of omentum had herniated through a perforation in the diaphragm and become gangrenous. Resection was followed by an uneventful recovery.
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TABLE 97.-Essential data in 14intra-abdominal injuries caused by blunt trauma and external blast
the missile entered the abdomen from the thorax, it lodged in the diaphragm and caused only a small opening in the peritoneum.
In none of the 17 abdominal wounds had the missile passedfreely across or through the general peritoneal cavity in a major diameter. Inevery instance, the peritoneal wound had been caused by missiles which hadeither perforated the cavity across small angles, lacerated the peritoneum inburrowing through extraperitoneal tissues, or so exhausted their momentum as tofall harmlessly into the peritoneal cavity.
Hemoperitoneum in varying degrees, all from extraperitonealsources, was present in most of the 41 cases. It was this blood, sometimes morethan a liter, which produced the clinical symptoms and signs of anintraperitoneal lesion.
Thesurgical approach in each instance was determined by the type of wound. In 20 ofthe 24 thoracoabdominal wounds, exploration was carried out through the chestand diaphragm. In two othercases, it was carried out through separate incisions in the chest and abdomen. The remainingoperations were performed through abdominal incisions.The wound of the diaphragm was sutured in all thoracoabdominal wounds.
There were 2 deaths in the 41 cases. One patient, who had sustained an evisceration of 18 inches of ileumthrough a wound of the abdominal wall, died unexpectedly, 3days after operation, ofmassive pulmonary embolism, the origin of which was not stated. In the other fatal case, a severe retroperitoneal injury with severanceof the left common iliac vessels, death occurred 10 days after operation, fromperitonitis, retroperitoneal cellulitis, and pneumonia.
The most importantobservation made in this group of cases is that in not a single instance did amissile pass harmlessly across the general peritoneal cavity in a majordiameter. Since the whole series represents a very large number of cases (3,154)and since the policy was to explore every injury in which there was evidence ofor suspicion of peritoneal penetration, it would seem that perforating wounds ofthe peritoneal cavity in which there is no injury of the intraperitonealstructures must be extremely uncommon. It is true that because of the tendencyof certain wounds of the gastrointestinal tract to seal over, clinical recoverymay occasionally ensue in such cases, without surgery and therefore withoutdiagnosis, but because of the excellent surgical service and facilities providedin forward hospitals in World War II, the risks involved in the nonsurgicalmanagement of this type of wound would not have been justified.
