CHAPTER III
Thoracoabdominal Wounds
Lyman A. Brewer III, M.D.
GENERAL CONSIDERATIONS
Definition-The term "thoracoabdominalwound" was reserved in World War II for a wound in which a single missilewas responsible for damage to structures of the chest and the abdomen. Inapproximately 90 percent of all cases, the missile entered the chest and passedinto the abdomen. As a rule, the term "thoracoabdominal injury"implied a perforation of the diaphragm. Occasionally, a missile that entered thechest could transmit sufficient force through all an intact diaphragm to producean abdominal injury, but this was most unusual. A wound of the so-called barearea of the liver produced by a fragment that entered the chest and perforatedthe diaphragm was considered a true thoracoabdominal wound.
The term "thoracoabdominal wound" should never havebeen used, as it occasionally was, for wounds in which both serous cavities wereinjured by separate missiles. The distinction is important. The management of acombined thoracic and abdominal wound inflicted by separate missiles and withoutperforation of the diaphragm differed considerably from the management of athoracoabdominal wound in which the injury of both cavities was produced by thesame missile and in which perforation of the diaphragm was a factor.Thoracoabdominal and combined thoracic and abdominal wounds resembled each otherin one respect, however, that both carried very high mortality rates.
Incidence-There was not complete agreement asto the incidence of these wounds.1 Theyaccounted for about 5 percent of all admissions for battle-incurred wounds inSeventh U.S. Army hospitals. Maj. (later Lt. Col.) Lawrence M. Shefts, MC, andCapt. (later Maj.) Ernest A. Doud, MC, who had a representative forwardexperience, found that thoracoabdominal wounds represented about a quarter oftheir intrathoracic wounds. The 903 thoracoabdominal injuries treated by the 2dAuxiliary Surgical Group amounted to almost 40 percent of the 2,267intrathoracic injuries which they encountered.
Management in field hospitals-About a quarter of thebattle-incurred injuries treated in field hospitals in the Mediterranean theaterwere thoracoabdominal injuries. Since casualties with these injuries were alwaysnontransportable, practically all were treated in these forward hospitals. The
1Official statistics for thoracoabdominal injuries appear in the first volume dealing with thoracic injuries (chapter II, tables 8-11).
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occasional casualty treated in an evacuation hospital had aninjury that had escaped recognition in the field hospital. The management ofthoracoabdominal injuries in base hospitals consisted of the management ofcomplications and the care and closure of colostomies.
As a group, casualties with thoracoabdominal wounds presented the severestinjuries of all battle casualties; furnished a high proportion of the admissionsto field hospitals, where, as just noted, most of them were treated; and had thehighest case fatality rate of any group admitted to them.
These wounds furnishedthe most important single indication for surgery of thoracic injuries in a fieldhospital, for two reasons, (1) that resuscitation was not complete withoutsurgical repair of the intraperitoneal damage, and (2) that in this type ofwound, immediate surgery was necessary to prevent or control intraperitonealcontamination. In thoracoabdominal wounds, whether the diagnosis was establishedor merely probable, surgery was indicated as soon as cardiorespiratory stabilitypermitted.
Attention has been called elsewhere to the necessity forthoracic surgeons assigned to field hospitals to be able to do intra-abdominalsurgery (vol. I). The large number of thoracoabdominal wounds that had to behandled in these installations was further proof of the need for this dualability. Even though the majority of casualties with injuries limited to thethorax could be evacuated to the evacuation hospitals after resuscitation, ifnot before, a single team could not handle the remainder of the casualties inthis group plus all of the casualties in the thoracoabdominal group.Thoracoabdominal injuries were practically always very serious, and a great dealof time was consumed in resuscitation and at operation. A desirable plan, whenavailable personnel permitted its use, was to assign a senior thoracic surgeonto a field hospital and place two teams under his direction. In this way, hecould supervise the management of all serious thoracic and thoracoabdominalwounds without attempting the usually impossible task of managing them allpersonally.
PATHOLOGIC PROCESS
The wound of entrance in thoracoabdominal wounds was in the thorax in thegreat majority of cases. In the 903 such wounds encountered by the 2d AuxiliarySurgical Group, the missile entered through the chest 837 times and through theabdomen 66 times.
Thoracic injuries-In most instances, theentering missiles caused fractures of the ribs; the level of the fracturestended to correspond with the zone of the diaphragm. In only 3 of the 903 woundsjust mentioned was the site of the costal fracture above the sixth ribposteriorly or the fourth rib anteriorly. The paucity of wounds in the upperchest is probably to be explained by the smaller size of the target and by thelethal effect of missiles which entered the thorax in a cephalad direction;these patients did not survive to reach a hospital.
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Pulmonary damage varied according to the site of injury. Whena costophrenic angle was crossed, damage was usually minimal. If the wound ofentrance was elsewhere, there was usually a perforation or a laceration of thelung. Contusions were less frequent. Hemorrhage was present along the track ofthe missile and for 1 to 3 cm. beyond it. In an occasional case, a segment ofthe lung was found amputated.
The mediastinum was injured 30 times, the heart 14 times, andthe pericardium alone 13 times in these 903 cases. There was only one injury ofthe esophagus.
In most cases handled by the 2d Auxiliary Surgical Group, on whose materialall of the following statements are based, the pulmonary wound was in theperipheral portions of the lower lobes because the missiles most often enteredthrough the lower chest in the zone of the diaphragm. Injuries of the middlelobe and of the lingula of the left upper lobe were much less frequent.
Diaphragmatic injuries-Injuries to the diaphragm (fig. 35) fellroughly into three categories:
1. Small single or double perforating wounds.
2. Large lacerated wounds.
3. Avulsion of the diaphragm from its attachment to the chest wall.
The wounds were almost equally distributed between the right(435 cases) and the left (448 cases) sides. In 20 cases, the diaphragm wasperforated bilaterally.
Herniation of abdominal contents through the diaphragm wasrecorded 57 times. In 17 instances, only the omentum protruded. The explanationof evisceration was the physiologic fact that pressure is normally lower withinthe chest than within the abdomen. As a result, the spillage of gastric andintestinal contents into the chest was always a possibility when the diaphragmhad been wounded.
Intra-abdominal injuries-The liver took theimpact of missiles which entered on the right side. It was involved in 407 ofthe 435 right-sided injuries. In the order of frequency after wounds of theliver (table 7) were wounds of the right kidney, colon, stomach, small bowel,and gallbladder. On the left side, the spleen, stomach, and colon took theimpact of most missiles entering on that side. In the 448 left-sided wounds, thespleen was injured 272 times, the stomach 167 times, and the colon 145 times.
There was no evidence of involvement of the thoracic duct inthese 903 cases. The assumption is that casualties with such injuries seldomsurvived long enough for their condition to be recognized.
Tension pneumothorax of peritoneal origin-Inthe 55 thoracoabdominal wounds encountered by Lt. Col. John M. Snyder, MC, andMaj. Frank Tropea, Jr., MC, 24 of which were left-sided, there were 2 instancesof tension pneumothorax of peritoneal origin. This condition, it was thought,had not previously been described. In each instance, the wound of entry was inthe lower left chest, and in each, there was a large perforation of the anteriorwall
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of the stomach, with a resultant outpouring of a large amount of air throughthe lacerated diaphragm. In the first case, the diagnosis was not made, anddeath occurred in the course of laparotomy. In the second, in which thecondition was recognized several hours after the patient was first seen, closeddrainage was instituted, and recovery was uneventful.
Theoretically, there seems to be no reason why tension pneumothorax ofperitoneal origin should not be possible under the circumstances described,
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Combination of organs | Cases | Deaths | Case fatality rate |
Liver alone | 297 | 35 | 11.7 |
Liver and kidney | 59 | 14 | 23.7 |
Liver and stomach | 30 | 11 | 36.6 |
Liver and small intestine | 9 | 1 | 11.1 |
Liver and spleen | 7 | 3 | 42.8 |
Liver and right colon | 7 | 4 | 57.1 |
Liver and left colon | 3 | 1 | 33.3 |
Liver, stomach, and colon | 8 | 5 | 62.6 |
Liver, kidney, and right colon | 5 | 4 | 80.0 |
Liver, stomach, and biliary tract | 6 | 4 | 66.6 |
Liver, stomach, and spleen | 11 | 3 | 27.2 |
Liver, small intestine, and left colon | 6 | 5 | 83.3 |
Stomach and spleen | 43 | 18 | 41.8 |
Stomach, spleen, and left colon | 8 | 4 | 50.0 |
Stomach, spleen, and kidney | 9 | 3 | 33.3 |
Stomach, spleen, and pancreas | 3 | 2 | 66.6 |
Stomach and left colon | 8 | 2 | 25.0 |
Stomach, small intestine, and colon | 8 | 2 | 25.0 |
Stomach and kidney | 4 | 1 | 25.0 |
Spleen alone | 95 | 10 | 10.5 |
Spleen and kidney | 27 | 4 | 14.8 |
Spleen and left colon | 19 | 4 | 21.0 |
Spleen, kidney, and left colon | 12 | 6 | 50.0 |
Spleen and small intestine | 9 | 0 | --- |
Kidney alone | 11 | 4 | 36.6 |
Left colon alone | 18 | 6 | 33.3 |
Left colon and small intestine | 6 | 3 | 50.0 |
Peritoneal cavity (penetration only) | 26 | 3 | 11.5 |
All other combinations1 | 115 | 73 | 63.4 |
When five organs or more were injured, the case fatality ratewas 100 percent.
though before autopsy established it in the fatal case, some doubt had beenfelt about it. A tension pneumothorax of peritoneal origin could scarcely occurin a thoracoabdominal wound on the right, but the possibility of what might betermed an internal sucking wound could reasonably be considered on the leftside. In this variety of wound, small quantities of air and intestinal contentscould be aspirated into the chest during the act of respiration, and therepeated aspiration of small quantities would alter the intrapleural pressureand lead to pulmonary collapse unless the sucking was promptly corrected.
During the laparotomy for a left-sided thoracoabdominal wound, an injury thatoriginated as an internal sucking wound would become an external sucking woundas soon as the peritoneum was opened. This is apparently what happened in thefatal case in this series. Next to the control of active hemorrhage,
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therefore, closure of the lacerated diaphragm was the firstduty of the surgeon who operated on a thoracoabdominal wound through alaparotomy incision. On the right, the liver usually sealed off thediaphragmatic wound.
In the early days of the war, many laparotomies wereperformed without endotracheal anesthesia, and as a result, when the abdomen wasopened, a tension pneumothorax developed through the perforation in thediaphragm. This complication ceased to be a problem after endotrachealanesthesia was in general use and surgeons became aware of the possibilities oftension pneumothorax of this origin.
DIAGNOSIS
In general, if the patient had a single wound of the thoraxand a single wound of the abdomen, the diagnosis was obviously a combinedthoracic-abdominal wound. If both wounds were in the abdomen, there was littlepossibility of diaphragmatic injury unless the costal cage was involved. If bothwounds were thoracic and if one was below the level of the fourth rib anteriorly,a thoracoabdominal injury might or might not be present.
Since not more than 10 percent of the missiles inthoracoabdominal wounds entered the body via the abdomen, the chief difficultyfrom the diagnostic standpoint was in determining the presence or absence ofabdominal injury in a patient with a known thoracic wound, in every one of whichpenetration of the abdomen had to be considered as a possibility until theinjury was excluded. There was no problem when roentgenologic examination showedthe retained foreign body to lie within the chest or showed that it had enteredthe abdomen. The diagnostic difficulties were posed by the missiles thatperforated the chest in the so-called diaphragmatic zone or penetrated it andlodged in the vicinity of the diaphragm.
Anatomic and Physiologic Considerations
The most practical method of diagnosing a thoracoabdominalwound was to keep constantly in mind that the diaphragm might be involved in anythoracic injury, most particularly in any injury occurring in the area boundedsuperiorly by the anterior end of the fourth rib and posteriorly by the level ofthe seventh rib, down to and including the twelfth rib at its inferior level(fig. 36).
Both physiologic and anatomic facts had to be borne in mindin making the diagnosis. It could be assumed that the pleural reflectionfollows, with reasonable accuracy, the outline of the periphery of the ribs andthe costal cartilages. For diagnostic purposes, the thickness of the diaphragmcould be ignored, and the peritoneum could be assumed to be in contact with thediaphragmatic surfaces of the pleura. The diaphragm, however, is not an immobilestructure which forms a perfectly horizontal partition between the chest and
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the abdomen. In these circumstances, diagnosis would be muchsimpler. Instead, the variables caused by its uneven configuration and thedistance through which it can move, tremendously increased its susceptibility toinjury, and, in turn, the susceptibility of abdominal organs to involvement inthe wound.
Because of the movement of the diaphragm, any wound of theentire lower left hemithorax might penetrate the division between the thorax andthe abdomen (fig. 36). Any wound below the seventh interspace posteriorly or thefourth rib anteriorly might injure the diaphragm if the patient was in theexpiratory phase of respiration at the time. Since the pleural reflectionextends down to the attachments of the diaphragm to the ribs and the costalarch, any wound at the level of the twelfth rib or above posteriorly, or anywound that involved the costal arch or above anteriorly, had to be considered apossible thoracoabdominal injury.
If the range of motion of the diaphragm on deep inspiration and expirationwere kept in mind, the cavities and organs involved in a wound of the chestmight reasonably be predicted by lining up the wounds of entrance and exit ifthe injury were perforating, or by lining up the wound of entrance with thepoint at which the missile was lodged within the body if the injury werepenetrating. Any missile, therefore, which passed through the area extendingfrom the level of the twelfth rib posteriorly to the level of the fourth ribanteriorly might or might not have entered both the pleural and the peritonealcavities.
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Since many wounds were inflicted while the soldiers wereprone, the increase in intra-abdominal pressure created by this position furtherraised the upper limits of the diaphragm.
If the patient was in deep expiration at the time ofwounding, the diaphragm, with the spleen and stomach, might rise high enoughinto the thoracic cavity to be injured by a missile that had entered the chestat the fourth interspace. If the wounding had occurred during the expiratoryphase of respiration, the anatomic position of the wounds in the chest wallmight be quite cephalad and yet there might be a tear in the diaphragm anddamage to the peritoneal organs. In one casualty, for instance, in whom thewound of entrance was in the fourth interspace just medial to the left nippleand the wound of exit was in the seventh interspace in the left midaxillaryline, the diaphragm was perforated and the spleen was injured.
Projection of Course of Missile
The most reliable and most helpful information in thoracicinjuries in which involvement of the abdomen was not evident by clinical meanswas obtained by projecting the probable course of the missile. Roentgenologicexamination was therefore essential in every penetrating wound of the chest, nomatter how insignificant it might seem, if only because the location of thewound of entrance was occasionally extremely misleading in relation to thecourse of the missile within the body.
Both anteroposterior and lateral films were made, with overexposure for bothabdomen and chest. They were preferably made in the sitting position. Patientsin severe shock, who could not tolerate the upright position, were examined byanteroposterior exposures made in the prone position.
When the information derived from films in two planes was correlated with itspoint of entrance, the course of the missile could be projected and a decisionmade concerning the possibility of intra-abdominal damage.
Missiles tend to travel in a straight line if they are not deflected. Theexperience of most surgeons who treated large numbers of war wounds was, aspointed out elsewhere (vol. I), that stories of missiles which entered at onepoint and caromed around at a tangent before making their exit or lodging atsome point within the body were the exception. There were occasional instancesin which the course of the missile was bizarre because it had struck a bonystructure tangentially, but these injuries, again, were exceptional. Manysuperficially bizarre pathways could also be explained by investigation of theposition that the casualty was occupying when he was injured. Inquiry on thispoint was made whenever the patient was sufficiently oriented to furnish theinformation.
On the other hand, an occasional thoracoabdominal injury diagnosed for thefirst time at a general hospital made it clear that exceptions to thesegeneralizations sometimes occurred. In one such injury, reported by Lt. Col.John Burke, MC, and Maj. Theodore T. Jacobs, MC, for instance, a wound of
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entrance in the region of the right scapula and a wound ofexit in the right groin were considered to be individual wounds. They proved tobe from the same missile. Fortunately, the delay in operation was not attendedwith serious consequences.
Clinical Considerations
Part of the diagnostic confusion in some thoracoabdominal woundswas caused by the overshadowing of symptoms and signs referable to the abdominalinjury by the more urgent symptoms and signs of the chest injury. The thoraciccomponent of the injury could give rise to pain in the chest wall, hemoptysis,hemothorax or hemopneumothorax, dyspnea, cyanosis, and wet lung.
Since thoracic wounds that did not involve the abdomen were frequentlyassociated with pain and spasm of the upper abdomen (vol. I), these phenomenadid not furnish a reliable indication of abdominal injury. Abdominal tendernessand rigidity were also often present; in such cases, a useful differential pointwas that deep tenderness and rebound tenderness were never elicited in chestwounds. If time could be spared, a differential diagnosis was sometimesclarified by paravertebral or intercostal block. The results were not alwaysconclusive, but when there was prompt relief of pain, abdominal involvementcould usually be excluded. Pain in the shoulder was not a universal symptom.When it was present, it pointed to an injury of the diaphragm.
Although nausea and vomiting sometimes occurred in thoracic injuries, theywere not common, and their presence lent strength to the possibility ofabdominal involvement. The demonstration of active peristalsis suggested that ifabdominal injury had occurred, a hollow viscus was not involved. Most surgeons,however, could recall casualties in whom peristalsis had been observed even withwounds of the colon. Peristalsis frequently persisted when the injury waslimited to the spleen, liver, or kidney. Wounds of all of these organs wereassociated with a paucity of symptoms and signs referable to the abdomen.
If a hollow viscus was injured, prompt surgery was imperative, but it wasimportant to remember that injuries of solid viscera could also be extremelyserious. A casualty might bleed to death from a damaged spleen, or grave or evenfatal bile empyema might be the consequence of an overlooked wound of the liver.
Other Diagnostic Aids
The presence of blood in gastric contents, whether vomited or aspirated, wassuggestive of abdominal injury, though it was not conclusive, since it mighthave originated from a wound of the lung.
Examination of a voided or catheterized specimen of urine was part of thediagnostic routine. The absence of blood in the urine was not conclusive, butits presence furnished valuable information as to the course of the missile inrelation to the urinary tract.
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Such diagnostic refinements as pneumoperitoneum were not practical in forwardhospitals.
EXPLORATION
IndicationsThe final diagnosis of a thoracoabdominal wound was based on the followingconsiderations:
1. Inspection of the wound or wounds.
2. The projection of the suspected course of the missile fromthe wounds of entrance and exit if the injury were perforating or fromroentgenologic localization of its position if the injury were penetrating.
3. Such information as could be obtained from the history and from thegeneral clinical picture.
If a positive diagnosis of a thoracoabdominal wound could notbe made with reasonable promptness and the suspicion persisted that thediaphragm might have been perforated, prompt exploration was the rule. Apositive preoperative diagnosis was naturally desirable, but if it could not bemade, a reasonable suspicion that such an injury existed was sufficientindication for exploration. In many instances, a somewhat enlarged traumaticthoracotomy provided adequate exposure to determine whether or not the diaphragmhad been perforated.
The only suspected thoracoabdominal injuries in whichexploration was not regarded as mandatory were minor penetrations of the liver.If a foreign body was only 2 or 3 mm. in diameter, and if roentgenologicexamination made it unmistakably clear that it lay entirely within the liver,expectant treatment was considered permissible in certain selected cases. Notmore than 1 percent of all thoracoabdominal injuries fell into this category,and many surgeons considered the risk of biliary empyema too considerable towarrant expectant treatment in any case at all. Whenever the foreign body wasover 3 mm. in diameter, regardless of its location, it was always best todetermine surgically the exact damage that had occurred.
Negative Explorations
A rather large number of exploratory thoracotomies had to beperformed because of the difficulty of making an accurate diagnosis of woundsaround the diaphragmatic sulci. For this and other reasons, a significant numberof negative explorations were carried out in all field hospitals. In the 2,267penetrating and perforating wounds of the chest cared for by thoracic surgeonsof the 2d Auxiliary Surgical Group, there were 903 proved thoracoabdominalinjuries, almost 40 percent. Teams from this group, however, performed 122exploratory thoracotomies in which no abdominal involvement had occurred.
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These 122 negative explorations represent 28 percent of all thoracotomiesdone by these teams in forward hospitals.
To surgeons without experience in combat wounds, this figuremay appear high. It is certainly high compared with the 41 explorations (1.3percent) performed by surgical teams of the group in 3,154 abdominal wounds inwhich no intraperitoneal damage of any consequence was found (1). On theother hand, it is significant that well over half of these 41 negativeexplorations (28) were in thoracoabdominal wounds. In these 28 explorations, asin the 122 negative explorations performed for suspected thoracoabdominal woundsin this series of thoracic injuries, the indication was the same: Injuries ofthe abdominal viscera are so highly lethal if they are not treated surgicallythat no chance of overlooking them could be taken.
A practical consideration in the diagnosis ofthoracoabdominal wounds was the echelon of medical care in which surgery wasdone. Casualties with thoracoabdominal wounds in which the diagnosis was clearcut were not transportable; surgery was done in field hospitals. Casualties inwhom thoracoabdominal wounds were suspected also had to be cared for in fieldhospitals. Exploration could not be delayed until they reached an evacuationhospital.2 If an abdominal injury were positively excluded, surgery for the chestinjury could usually be deferred until an evacuation hospital was reached.Unnecessary exploration put an added strain on the space, facilities, andpersonnel of the field hospital, but it could not be omitted in any doubtfulcase.
RESUSCITATION AND PREOPERATIVE PREPARATION
General Considerations
Certain concessions to the realities of the situation had to be made in theresuscitation and preoperative preparation of casualties with thoracoabdominalinjuries. The exigencies of the abdominal emergency were sometimes met at theexpense of the most ideal preparation of the casualty from the point of view ofcardiorespiratory stabilization.
From the standpoint of pure thoracic injuries, the length oftime required, within reasonable limits, to restore thoracic casualties to asnearly normal status as possible before operation was not of primary importance.If the injury was limited to the thorax, the casualty frequently was benefitedby a short period of stabilization after cardiorespiratory abnormalities hadbeen corrected and shock controlled.
In casualties with thoracoabdominal wounds, the situation wasentirely different. Time was of great importance. They had to be resuscitated asexpeditiously as possible and operated on as soon as it was thought that they
2In certain military situations, evacuation hospitals served as the most forward hospitals in the area and acted in the capacity of field hospitals. In these circumstances, they operated on all nontransportable casualties.
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could tolerate surgery. If a patient continued to have a lowblood pressure, rapid pulse, and associated signs of shock after correction ofthe disordered thoracic physiology, supplemented by adequate replacementtherapy, immediate surgery was indicated. Many patients who presented such apicture were found at operation to be bleeding seriously or to have massivepleural or peritoneal contamination from a perforated stomach or intestine.Their condition was frankly dangerous with immediate surgery, but entirelyhopeless without it.
Patients with thoracoabdominal injuries were examined in theshock tent to determine their status in respect to shock and theircardiorespiratory status as manifested by respiratory restriction due to pain,embarrassment of respiration by hemothorax or pneumothorax, cyanosis, andexcessive accumulations of blood and mucus in the tracheobronchial tree. In 669thoracoabdominal injuries in the 2d Auxiliary Surgical Group records in whichinformation is available on this point, 145 patients were not in shock but 75were in mild shock, 174 were in moderate shock, and 275 were in severe shock.
Routine of Resuscitation
When thoracoabdominal casualties were received in the fieldhospital from the division clearing station, measures to combat shock andmaintain respiratory equilibrium would already have been instituted. Suckingwounds of the chest would have been closed by occlusive dressings. Pain wouldhave been relieved by morphine if it was indicated, or by intercostal nerveblock. Plasma transfusions would also have been given as necessary. The 2dAuxiliary Surgical Group records in which information is available on this pointshow that 144 casualties had received no plasma, but 455 had received an averageof 525 cc. each.
The records also indicate that while 60 casualties received no blood in theshock tent, 619 had an average of 1,100 cc. each. It is known that 252casualties received no plasma in the shock tent and that 408 received an averageof 500 cc. each. The usual practice was to begin the administration of plasma inthe shock tent while waiting for blood to be cross-matched.
While plasma and blood were being administered, measures wereinstituted to correct the disordered cardiorespiratory physiology, including theadministration of oxygen through a nasal catheter or mask (vol. I); intercostalnerve block if it had not already been carried out (vol. I); aspiration of airand blood from the pleural cavity (vol. I); and catheter or bronchoscopicaspiration of the tracheobronchial tree (p. 227). As a rule, the effect of thesemeasures upon the cardiorespiratory imbalance and on the state of shock to whichit was contributing was most gratifying.
As pointed out already (vol. I), a patient with a thoracicinjury had to be treated judiciously in respect to replacement therapy becauseof the grave danger of overloading the already damaged cardiorespiratory systemand pre-
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cipitating pulmonary edema. The same precautions had to beobserved in thoracoabdominal injuries. However much the casualty might needblood from the standpoint of the abdominal component of his wound, there wasserious risk from the standpoint of the thoracic component in giving largeamounts acid in giving them too rapidly.
An important step in preoperative management was the introduction of a Levintube, to aspirate the gastric contents and thus eliminate the risk of vomitingduring surgery (vol. I).
It was a general policy to transport the patient from the shock tent to theoperating table on the litter on which he had been placed originally, to operateon him on the same litter, and to move him to the recovery tent on it.Casualties with abdominal and thoracoabdominal wounds, particularly those whohad been in serious shock, did not tolerate movement well, and this planeliminated it while at the same time saving the time and effort of busypersonnel.
Priority of Surgery
Uness severe intro-abdominal hemorrhage, which was not usual,demanded priority of treatment, the necessary intrathoracic surgery tookprecedence of the abdominal surgery. The importance of this sequence is evidentin 15 deaths analyzed by Maj. (later Col.) Howard E. Snyder, MC, Consultant inSurgery, Fifth U.S. Army (2). In only one of seven cases in whichlaparotomy preceded chest surgery was there any indication for performing itfirst, and there seemed no doubt that the unwise order of precedence played apart in more than one of the fatalities.
ANESTHESIA
The anesthesia of choice in thoracoabdominal wounds was endotracheal etherand oxygen in a closed circuit, with induction by nitrous oxide and oxygen. In asmall number of cases, Pentothal sodium (thiopental sodium) was used for thispurpose. In 1942 and part of 1943, open drop ether was used in many operationsbecause of the limited number of anesthetic machines. This technique wasdiscarded as soon as these machines became generally available.
It was impossible to overemphasize the value of endotrachealanesthesia, in thoracoabdominal surgery or of the services of an expertanesthesiologist. Such an anesthesiologist appreciated the valve of frequent andthorough aspiration per catheter of the tracheobronchial tree throughout theoperation; of bronchoscopy in selected cases at the end of operation; ofreplacement therapy during operation; and of positive pressure anesthesia whenthe thoracic cavity was open as well as during closure of the chest, whenreexpansion of the lung was necessary.
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Replacement therapy was carried out during surgery, the useof whole blood, plasma, or glucose or physiologic salt solution depending uponthe needs of the individual patient. The records of the 2d Auxiliary SurgicalGroup that are complete in this respect show that 116 patients required nofluids on the operating table, 639 had an average of 1,000 cc. each of blood,166 an average of 575 cc. each of plasma, and 78 an average of 1,000 cc. each of5 percent glucose in physiologic salt solution in addition to the plasma andblood they received.
The casualties operated on by teams of the 2d Auxiliary Surgical Group werekept under anesthesia on an average of 2? hours.
SURGICAL APPROACH
General Considerations
At the beginning of the fighting in North Africa, it wasgenerally thought that the transdiaphragmatic approach to the abdominalcomponent of thoracoabdominal wounds would be of only limited usefulness. Atthat time, and to a certain extent throughout the war, the decision as to thesurgical approach depended not only upon the findings in the particular case butalso upon the preference of the surgeon for the abdominal or thoracic approach.This preference usually depended, in turn, upon his experience, or lack ofexperience, in chest surgery. The experienced chest surgeon was able to selectthe single approach or the combined approach which best met the needs of thepatient. Surgeons not widely versed in thoracic surgery found it safer to repairthe intraperitoneal damage through a laparotomy incision after handling thethoracic damage and closing the diaphragm through the chest.
By the end of the war, it was the opinion in theMediterranean theater-an opinion shared by the more experienced of the thoracicsurgeons in the European theater-that whenever it was practical, thoracotomywith transdiaphragmatic repair of all accessible abdominal injuries wasinfinitely the procedure of choice. If total repair was not possible by thetransthoracic approach, the best plan in left-sided wounds was to correct theintrathoracic damage, care for any damage readily accessible in the left upperquadrant of the abdomen, close the diaphragm, reexpand the lung, close the chestwall tightly, and then proceed with the repair of intraperitoneal injuries notaccessible through the diaphragm. The same general principle was applicable towounds of the upper right quadrant of the abdomen, but the extent of surgerypossible in this quadrant was, for anatomic reasons, much less than on the leftside.
When the thoracic and abdominal wounds were separate, transdiaphragmaticsurgery was not indicated because it subjected the pleura to contamination whichdid not already exist. In these cases, the chest wound was given priority unlessprofuse intra-abdominal bleeding or massive evisceration made laparotomynecessary as the primary procedure.
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Advantages and Disadvantages of the Transthoracic Approach
No hard-and-fast rule, covering all casualties, could be laid down for theapproach to a thoracoabdominal wound. There were advantages and disadvantages toboth the thoracic and the abdominal approaches, and each casualty had to beindividualized.
In favor of the transthoracic approach were the following arguments:
l. If there was extensive thoracic damage, the chest injuries could not berepaired from below the diaphragm.
2. Certain wounds of the upper abdomen were more easily handled through thediaphragm than through a laparotomy incision. These included wounds of thespleen, the dome of the liver, both kidneys, the upper portion of the stomach(especially if the posterior surface was injured), and the splenic flexure ofthe colon. There was real danger of overlooking wounds of the posterior wall ofthe stomach and of the retroperitoneal portion of the splenic flexure, as wellas wounds of certain areas of the spleen, when the approach was by laparotomy.
3. Injuries of the diaphragm, whether on the right or the left side,especially if they were extensive, were more readily repaired transthoracically.If the wound was small, it could as well be repaired from below as from above.Injuries over the dome of the liver, however, as well as such large defects asresulted from tearing of the diaphragm from the costal margin, especiallyposteriorly, were much more readily repaired from above.
4. The transthoracic approach permitted exteriorization ofthe transverse or splenic flexure of the colon through a subcostal gridironincision at a greater distance from the surgical incision than was possible iflaparotomy had been done. Wound infection was thus reduced to a minimum.
5. If considerable pleural contamination had occurred from spillage ofgastric or intestinal contents, it could be reduced by copious pleural lavagewith physiologic salt solution, a procedure possible only through the chest.
6. There was no validity to the objection, sometimes raised, that wounds ofthe gastrointestinal tract should not be dealt with through the chest becauseinfection of the pleural cavity might result. For one thing, considerable damageto the intrathoracic organs might exist without being evident before the chestwas explored. For another, potential infection existed whenever the diaphragmhad been perforated by the missile. If hollow organs in the abdomen had beenperforated, feces and gastric contents had been sucked into the pleural cavitybefore the surgeon ever saw the casualty.
7. If the chest was long and narrow, with an acute angle at the costal arch,subdiaphragmatic repair was often technically very difficult.
8. Blockage of the intercostal nerves, for anatomic reasons, was much easierwhen the transthoracic approach was used. These nerves lie underneath the ribsand course downward diagonally to supply the upper abdomen. When they wereblocked at operation, both thoracic and abdominal pain was decreased. As aresult, after operation, the patient coughed willingly, and as
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a further result, the lungs were more adequately aerated and bronchialsecretions were raised more completely.
9. Since abdominal relaxation was not necessary when the transthoracicapproach was used, the patient could be carried in a lighter plane ofanesthesia.
10. If the transthoracic approach revealed intra-abdominal injuries thatcould not be repaired from above, it was a simple matter to perform thenecessary chest surgery, close the diaphragm and chest wall, and then performthe necessary intraperitoneal surgery through a separate laparotomy incision. Asalready emphasized (p. 113), in the absence of compelling reasons for reversingthe order, chest surgery was always done first, in order to restore normalcardiorespiratory conditions as promptly as possible.
Against these multiple advantages of the transthoracicapproach were the following arguments for repair of intraperitoneal damagethrough a laparotomy incision:
1. Certain wounds of the small bowel and colon could not be exposedadequately through the diaphragm and had to be repaired by laparotomy. Theseincluded wounds of the terminal 18 inches of the small intestine and all woundsof the colon except wounds of the transverse portion, the splenic flexure, andthe proximal portion of the descending colon.
2. When thoracic damage was minimal, an abdominal approachavoided unnecessary entrance into the pleural cavity. This was not a soundargument. When the abdomen was opened, all but the most minimal perforations ofthe diaphragm constituted, in effect, sucking wounds, which carried all therisks of sucking wounds of the chest wall (p. 105). Not infrequently, patientsdeveloped pulmonary embarrassment while the abdominal repair was in processbecause of aspiration of air into the chest through the diaphragmatic opening.If the situation was unrecognized and uncorrected, serious results could follow,including aspiration into the pleural cavity of intestinal and gastric contentsfree in the peritoneal cavity. If the abdominal approach was used, repair of thediaphragm was necessarily the first step of the procedure, to avoid thesedangers, instead of the last before wound closure, as in the transthoracicapproach.
INCISION
Four types of incisions, in addition to separate thoracic and abdominalincisions, were employed in thoracoabdominal wounds:
1. Limited thoracotomy, accomplished by an extension of the original wound(traumatic thoracotomy). This was often a satisfactory incision when injurieswere confined to the chest. It was not usually satisfactory in thoracoabdominalwounds unless the original injury in the chest wall was large enough to supplyadequate exposure, which was essential for exploration of the upper abdomen andrepair of damaged intra-abdominal viscera. If the original wound was below thetenth rib, and especially if the missile had gone through the eleventh or thetwelfth rib, traumatic thoracotomy was entirely
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impractical. Even resection of one or more ribs did not provide satisfactoryspace for maneuvers. Wide exposure was essential. If there was any reason forinspection of the interior of the thorax, there was every reason for adequateinvestigation.
2. Thoracotomy in the area of the original wound.
3. Thoracotomy outside the area of the original wound. The majority ofthoracotomies fell into either this group or the second group. The formalapproach was usually posterolateral and usually through the ninth intercostalspace or the bed of the ninth rib. Injuries of the mid or anterior portions ofthe diaphragm were often approached through the eighth interspace or the bed ofthe eighth rib. A small number of thoracotomies were performed laterally, in theregion of the sixth or seventh ribs, more often through the intercostal spacesthan through the bed of the ribs. It was always best, if it was anatomicallyfeasible for good exposure, to resect a rib that was not involved in the wound ofentrance or exit, in order to reduce the chances of postoperative woundinfection with involvement of the diaphragm.
4. Thoracolaparotomy, an incision in which the thoracic incision was extendedthrough the costal arch onto the abdomen. This was not a popular incisionbecause of the resulting instability of the chest wall and the increasedmorbidity if infection occurred in the costal cartilages. It was used only sixtimes in the 903 thoracoabdominal wounds cared for by the 2d Auxiliary SurgicalGroup. In two of these injuries, the rib margins had been destroyed by theoriginal wounds, and this approach was used as a matter of expediency. In one ofthe four other cases, in all of which the incision was elective, the wound brokedown and the resulting infection was fatal. Most chest surgeons believed therewas nothing to be said in favor of this approach as an elective procedure.3
TECHNIQUE
Management of the Thoracic Component
The thoracic component of the thoracoabdominal wound was treatedin much the same manner as if it were the only wound. The principal differencewas that, because of the abdominal element and the transthoracic approach, manychest wounds were treated by thoracotomy in field hospitals that otherwise wouldhave been treated in evacuation hospitals and only by debridement andthoracentesis. Once the thoracic cavity was entered, there would have been nopoint to not removing intrapulmonary foreign bodies and bone fragments, though aprolonged search for small missiles was not warranted. Pulmonary lacerations ofmore than 4 or 5 cm., as well as any lacerations which demonstrably leaked air,were repaired with interrupted sutures.
3The long vertical abdominal incision introduced by Duval in World War I does not seem to have been employed in World War II. It was used by Wangensteen after World War I, and it was employed by Norwegian surgeons in a forward hospital during the Korean War.-F. B. B.
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Management of the Abdominal Component
Standard practices were also followed in the management of theabdominal component of the wound. In brief, wounds of the stomach were sutured.Wounds of the small intestine were treated by suture or by resection andanastomosis, according to the indications. Wounds of the colon were exteriorizedor managed by colostomy. Wounds of the spleen were treated by splenectomy.Wounds of the pancreas were treated by suture and drainage or by drainage alone.Wounds of the kidney were preferably treated by drainage; nephrectomy wasperformed only when the pelvis was definitely involved or when hemorrhage wasintractable. The management of all of these wounds is described in detail in thevolume on general surgery devoted to abdominal injuries (1).
Wounds of the liver-Wounds of the liver require special mention. Evenif only a small fragment had penetrated the liver substance, it was conservativemanagement to explore the wound, since it was not possible to determine from thesize of the missile the precise site of the diaphragmatic laceration or theextent of hepatic damage. In some instances, particularly when a rib had beenfragmented, a surprising amount of diaphragmatic and hepatic damage was causedby the passage of a small missile.
Experience in World War II soon showed that any wound of the liver thatwarranted exploration also required drainage. A wound too small to demanddrainage was almost never encountered. It is quite true that bile did not drainafter operation in some cases, but there were no criteria by which the injuriesin which this would happen could be identified at operation. The size of themissile was not the deciding factor. If a small missile cut across a main bilepassage, drainage was more profuse than it might be after a more superficialhepatic wound of greater extent. The larger bile radicles were frequentlyinvolved in wounds that looked innocent.
If drainage was omitted and infection developed, the resulting draining sinusoften took weeks to close. In other cases, the diaphragmatic repair broke down,particularly if the perforation was over the bare area of the liver over whichthere is no peritoneum. The pooled blood and necrotic material from the damagedliver readily broke through the unfortified diaphragmatic suture line. Theresulting biliary pleural fistulas were difficult to treat, and there was morethan a casual relation between them and pleural empyemas.
The use of gauze packs was abandoned early in the war as bothinefficient and hazardous. They gave rise to subphrenic, subhepatic, or pelviccollections of bile, often with associated abscess formation. Since thediaphragm was perforated in all thoracoabdominal wounds, bile and exuded fluids,whose external discharge was prevented by the pack in the liver, tended to forcetheir way through the sutured diaphragmatic wound, no matter what the techniqueof suture, with resulting biliary fistulas and bile empyemas. In some instances,the thoracotomy incision broke down, and pleurocutaneous fistulas developed.
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In two cases, in which the lung was adherent to the suture line in thediaphragm, a serious problem was created when the bile eroded into a bronchus.
Other disadvantages connected with the use of gauze packsconcerned their removal, which was usually painful and was often followed bysecondary hemorrhage. In one such case in the experience of the 2d AuxiliarySurgical Group, the granulation tissue that had invaded the meshes of the gauzebled so profusely when the pack was removed that the patient was exsanguinatedbefore surgical intervention could be undertaken. Autopsy showed vascularizationof the liver bed as a reaction to the presence of the pack.
Complications associated with the use of gauze packs were sonumerous and so troublesome that their use was eventually discontinued, andPenrose drains were substituted for them. These drains, however, weresatisfactory only when the drainage incision was of adequate size not only onthe surface but through all layers of the drainage tract. It was also essentialthat they be placed under direct vision when the abdomen was still open.
Adequate drainage implied the proper placing of two or threelarge, soft rubber drains to the site of the liver damage through an adequateanterolateral subcostal incision. The incision was not adequate unless it was atleast 3 inches long. A tract was established extraperitoneally by bluntdissection until the upper surface of the liver was reached; then the peritoneumwas broken through. The drains were placed precisely, under direct vision,before the diaphragm was closed. Often both anterior and posterior drainage wasdesirable. Drains to the liver were never brought to the surface through thethoracotomy incision or the laparotomy incision. This would have been aninvitation to wound infection and disruption.
There was a significant reduction in the complications caused by inadequatedrainage of wounds of the liver as the principles of drainage became moreclearly understood and the proper techniques were put into effect. Constantemphasis upon both principles and practices was, however, necessary throughoutthe war.
Closure of the Diaphragm
The rent in the diaphragm was repaired as securely as possibleto forestall the development of bile empyema on the right side and ofdiaphragmatic hernias, which were more of a threat on the left than on the rightside. When thoracotomy and laparotomy had been done as separate procedures, thediaphragm was preferably repaired from above, through the thoracotomy. Closurefrom below was much more difficult and much less satisfactory.
The anesthesiologist had much to do with the ease with whichthe diaphragm was closed. If he initiated a period of controlled respiration,thus securing complete diaphragmatic relaxation and immobility, closure wasgreatly facilitated. Relaxation was particularly important when the closure hadto be effected in a site that would not have been the site of election: in warwounds, the surgeon had no choice.
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Several techniques were used to close the diaphragm, a 2-layer closure beinggenerally regarded as most satisfactory. It was accomplished either byimbrication of 2 cm. of diaphragmatic tissue or by simple approximation of thewound edges, reinforced by a second layer of inverting mattress sutures. Neitherof these techniques was practical through an abdominal approach.
Crushing of the phrenic nerve was practiced only where there had been actualloss of muscle tissue, so that closure under tension would otherwise benecessary.
Silk or cotton sutures were used, sometimes combined withchromic catgut. Silk was used in 373 of the 636 cases in which 2d AuxiliarySurgical Group records have information on this point. Sutures were alwaysinterrupted.
Special techniques were necessary for special wounds. Anapparent defect in the lateral costal margin of the diaphragm, which was theresult of contraction or avulsion after severance of its attachments, wascorrected by suturing the diaphragm to an intercostal muscle one or more spaceshigher than its original attachment. Reattachment was important, for theoriginal site of attachment was usually in the area of the chest wall wound,with its accompanying fractures, and this structure was no longer stable enoughto permit efficient diaphragmatic action.
When the diaphragmatic crura had been torn from the vertebralcolumn, the first layer of sutures had to be passed through the superior surfaceof the liver. A sufficient number of these sutures always held to fix the liveragainst the undersurface of the diaphragm and thus prevent herniation.
Pleural Lavage
Before the chest wall was closed, all blood was suctioned outof the hemithorax, and it was adequately flushed with physiologic salt solution(vol. I). This measure was particularly important if there had been soiling ofthe cavity by gastric or intestinal contents.
Drainage
Whether to institute drainage of the pleural space atoperation or to rely upon keeping it empty after operation by thoracentesis wasa matter of prime importance in securing reexpansion of the lung. The decisiondepended upon a number of considerations, including the extent of pulmonarydamage; the magnitude of the laceration in the diaphragm; the size of the defectin the chest wall; and, most important, whether or not the pleura had beengrossly contaminated through the diaphragm from a perforated abdominal viscus.
Unless the defect in the thoracic wall was small, pulmonary and diaphragmaticinjuries minimal, and gross contamination of the pleural and peritoneal cavitiesabsent, it was not safe to omit water-seal intercostal drainage and to rely uponpostoperative thoracentesis to keep the pleural cavity free of blood and air.When water-seal drainage was employed, the chances of pleural
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infection were reduced, and, if it did occur, the process was limited andlocalized because there was no pleural dead space.
According to the records, closed water-trap intercostaldrainage was instituted in 326 of the 903 thoracoabdominal injuries cared for byteams of the 2d Auxiliary Surgical Group. The practice was to use either a largefenestrated catheter or a tube of equal caliber; both were rigid enough not tocollapse. The site of drainage was a separate intercostal stab wound, usually inthe posterolateral or lateral aspect of the lower chest. A small additionalcatheter was sometimes placed in the second interspace anteriorly, for theescape of air trapped in the upper pleural cavity.
Closure of the Chest Wall
Closure of the thoracic cage was accomplished by approximation of adjacentribs or of the intercostal musculature, depending upon whether thoracotomy hadbeen performed through the bed of a rib or through an intercostal space. Ifthere were large defects in the thoracic wall, contiguous musculature wasutilized in layers. In closing the posterior aspect of the pleural incision, itwas often useful to pull the paraspinalis muscle over the suture line foradditional reinforcement. The muscular layer was always closed, but thesubcutaneous tissue and skin were usually left open for subsequent closure.
SPECIAL SURGICAL CONSIDERATIONS
Special surgical conditions in the management ofthoracoabdominal wounds depended upon (1) which side they were located, and (2)whether they were penetrating or perforating.
Right-Sided Wounds
Perforating wounds-When the wound on the right sidewas low in the costal margin or in the region of the tenth, eleventh, or twelfthribs posteriorly, possible injury of the gallbladder, liver, duodenum, colon,and kidney had to be borne in mind. Exploration by the transdiaphragmatic routewas often not satisfactory in injuries in these locations because the liverblocked vision and prevented adequate exploration.
Debridement of the wounds of entrance and exit and investigation of thestatus of the diaphragm through a traumatic thoracotomy sometimes revealed thatonly the diaphragm and liver, or sometimes the kidney, had been damaged. If thethoracotomy was as low as the tenth interspace posteriorly, the liver could bedrained or the kidney sutured or removed through the diaphragm.
Wounds of the diaphragm no higher than the eighth interspace and no fartherposterior than the posterior axillary line could be exposed and sutured fromwithin the abdomen. The condition of the patient determined whether lacerationsof the diaphragm in other areas should be repaired at this time.
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Failure to repair a laceration of the diaphragm might lead toa biliary pleural fistula, but the possibility of this complication was not ofmajor importance in a patient in such poor condition that he could not toleratefurther surgery.
Early surgical intervention was imperative when the rightlobe of the liver continued to bleed into the pleural cavity or when the spleenlay shattered in the left pleural cavity. The situation was evaluated on thebasis of the location of the wound of entry, the position of the fragment, andthe lack of response to shock therapy. It was often necessary to operate withoutdelay in spite of persistent hypotension.
It was also possible to drain a wound of the liver through a traumaticthoracotomy in this location. The most satisfactory plan was to lay Penrosedrains over the rent in the liver and exteriorize them subcostally by breakingthrough the lateral reflection of peritoneum over the right lobe. Whatever thetechnique used, drainage was essential.
When there was no urgent indication for laparotomy before thoracotomy, thefirst attention was given to the chest wound. After debridement, closure of thechest wall, insertion of an intercostal tube, and aspiration of all blood andair in the pleural cavity, it was surprising to find how often the patient'scondition had improved and how much better he tolerated extensiveintra-abdominal surgery. The intercostal tube was drained into a water-trapbottle, and it was thus possible to check on the amount of hepatic bleeding. Thedrainage of blood into the pleural cavity, which would otherwise have occurred,might have considerably lowered the already impaired vital capacity by the timelaparotomy was concluded.
An extrapleural approach was used in an occasional thoracoabdominal injurylow on the right side posteriorly, but only if the thoracic injury was notsevere and if it was quite certain that the liver was the only abdominal organinjured. The eleventh or twelfth rib was resected, and the reflection of thepleura was dissected up. The pleural defect, being thus exposed, was thenrepaired, after which the liver was approached either through the perforation inthe diaphragm made by the missile or through the bed of the resected rib. Theoperation was performed exactly as drainage for a subphrenic abscess would beinstituted. In selected cases, this was a safe and simple way of draining woundsof the liver.
Penetrating wounds-When a penetrating wound was on theright side, it was necessary to investigate whether the missile had passedthrough the right lobe of the liver or had entered the peritoneal cavity. As ageneral rule, the laparotomy approach was best when roentgenologic examinationshowed the missile to be in the peritoneal cavity. If roentgenologic examinationindicated that it had stopped in the liver, the procedure was the same as forright-sided perforating wounds; that is, drainage of the suprahepatic space andrepair of the diaphragm. If the fragment was readily accessible, itwas removed, but protracted exploration for a buried intrahepatic foreign bodywas not wise, for it often resulted in considerable hemorrhage. Drainage, as al-
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ready pointed out (p. 118), was mandatory to guard against subphrenic spaceinfection and bile empyema.
Left-Sided Wounds
Perforating wounds-Possible injury to the left diaphragm was always initself a sufficient indication for thoracotomy. It was a simple matter, in theprocess of handling a sucking wound, to enlarge the wound and determine thestatus of the diaphragm. Since the chest wall is relatively thin in the lowerthoracic cage, most wounds were sucking.
Penetrating wounds-Accurate localization of the missile was importantin left-sided penetrating wounds in order to determine the surgical approach.Any damage done to intraperitoneal organs by a missile that entered the leftupper quadrant of the abdomen and remained in it could easily be reached andremedied through a transdiaphragmatic approach, with greater technical ease, infact, than was possible at laparotomy. If, however, the missile had passed intoany other quadrant of the abdomen, laparotomy was necessary.
The left transdiaphragmatic approach had many technical advantages. Throughit the following procedures (fig. 37) were readily performed: Splenectomy;exploration and repair of the entire stomach from the esophagogastric junctionto the duodenum; examination and mobilization of the colon from the hepaticflexure to the first portion of the sigmoid loop; examination of the hepaticflexure itself, by blindly taking down the hepatocolic ligament; repair of thecolon, or subcostal or midline exteriorization of either loop, or spurcolostomy; examination of the small bowel from the ligament of Treitz to withina few inches of the cecum, with resection or anastomosis as necessary; andvisualization and removal of the left kidney.
The abdominal approach was required for repair of wounds of the, lower ileumand cecum and of wounds of the colon from the hepatic flexure to the uppersigmoid. These structures could not be adequately exposed through the diaphragm.
The abdominal approach was also wisest when thoracic damage was so slightthat no intrathoracic surgery was necessary. If the diaphragm could be repairedfrom below in these cases, it was best not to enter another serous cavity.
When the foreign body was in the left upper quadrant of the abdomen and thewound of entrance was not sucking because the missile had traversed the chestwall obliquely, it could be assumed that pleural contamination had not occurred.The decision then had to be made whether to perform laparotomy or to employ atransthoracic approach, with the possible risk of pleural contamination. Manysurgeons, on the basis of their personal experience, thought the minimal riskjustified because of the greater technical ease of repair of intraperitonealstructures through this approach. The chances of infection were small with anexperienced surgeon, who bore in mind the importance of
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a fully expanded lung, a dry pleural cavity, and proper attention to pleurallavage and pulmonary expansion during closure of the thoracotomy.
The following technique for left-sided thoracoabdominal wounds was reportedby Major Shefts and Captain Doud:
After the patient had been anesthetized, he was placed on his right side,with a folded blanket under the lower lateral aspect of the right costal margin.A long strip of adhesive placed over the left hip and attached to the litteranteriorly and posteriorly helped to hold the position. The left leg was flexedat the hip and knee, and a pillow was placed below the knee. With the right legextended, the great saphenous vein anterior to the medial malleolus or at themiddle border of the tibia was available if the administration of fluids duringthe operation should prove necessary.
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The rib chosen for resection varied with the habitus of thepatient and could be determined during debridement of the wound. The bestapproach was usually through the bed of the resected ninth rib. Resectionstopped short of the costal cartilage, to prevent the chondritis possible ifcontamination should have occurred. When the diaphragm was opened, theperforating wound was included in the incision whenever that was possible.
When it was necessary to explore the stomach, access to the posterior wallwas obtained by opening the gastrocolic omentum. For exposure of injuries in theregion of the esophagogastric junction, especially those on the side of thelesser curvature, it was necessary to cut the left triangular ligament andmobilize the left lobe of the liver.
When splenectomy was indicated, the lateral reflection of peritoneum over thespleen was cut and the spleen delivered into the opening in the diaphragm. Theoperation was technically easier if, after the spleen had been delivered, thesurgeon and his assistant changed sides. The assistant maintained the spleen inposition with his left hand, while the surgeon passed his fingers beneath thesplenic pedicle. With this maneuver, the risk of injury to the greater curvatureof the stomach and the tail of the pancreas was greatly decreased.
To expose the left kidney, the lateral peritoneal reflectionof the upper portion of the descending colon was cut, together with thelienocolic ligament, and the colon was retracted mesially. Nephrectomy wasreadily performed through this approach.
POSTOPERATIVE CARE
In general, the postoperative care of the casualty with athoracoabdominal wound consisted of the care that would be given to him if hehad a chest wound only (vol. I) plus the management of an abdominal wound only.The routine of the postoperative care of casualties with abdominal wounds isdescribed in detail in the volume of this series dealing with these wounds (1)and need not be repeated here.
As a general rule, the absence of an abdominal incision made for a smootherconvalescence because abdominal discomfort and distention were less. Since hewas more comfortable, the patient was likely to be more willing to cooperate inthe measures necessary for promoting pulmonary expansion and keeping thetracheobronchial tree clear.
Routine of Management
Measures directed to the respiratory system-Before apatient with a thoracoabdominal wound was removed from the operating table, thetracheobronchial tree had been cleared by aspiration or, if necessary, bybronchoscopy. Bronchoscopy was employed in 110 of the 903 thoracoabdominaloperations done by surgeons of the 2d Auxiliary Surgical Group. If the patientshowed any cyanosis or respiratory difficulty, oxygen was administered at once.
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As soon as the patient was conscious, he was given instructions for deepbreathing, frequent coughing, and turning from side to side. If he could not orwould not cough voluntarily, intercostal nerve block was carried out if it hadbeen omitted at operation.
Tracheal aspiration by catheter was also begun and was repeated as frequentlyas necessary as long as there were detectable amounts of blood or mucus in thetracheobronchial tree. Often after the first tracheal aspiration, the patientcoughed voluntarily and without protest and kept the air passages clear by hisown efforts. If he could not or would not cooperate, or if catheter aspirationwas unsatisfactory, bronchoscopy was resorted to promptly. It was performedafter operation in 12 of the 903 thoracoabdominal wounds cared for by members ofthe 2d Auxiliary Surgical Group. Atropine gr. 1/100 was given intravenously from10 to 15 minutes before it was begun, to eliminate the risk of vagovagal reflex.Bronchoscopy could be performed quickly and easily on the ward because mostmembers of thoracic surgical teams-surgeons, assistant surgeons, andanesthesiologists-were all trained to perform it.
If the ward was busy and repeated observation was not practical, it was thebest plan to use an oral or nasal airway to maintain patency of the respiratorypassages. At least one thoracoabdominal casualty is known to have died ofstrangulation 3 hours after operation because this precaution was omitted on abusy postoperative ward.
Replacement therapy-Replacement therapy was continued after operationaccording to the indications. The amount of blood and plasma administereddepended upon the hemoglobin, hematocrit, and serum protein determinations.Between 2,000 and 3,000 cc. of 5 percent glucose in physiologic salt solutionwas given daily. This amount was not usually exceeded because it was stillpossible to overload the circulation and produce pulmonary edema.
Gastrointestinal decompression-All patients with thoracoabdominalwounds were treated by nasal intubation and gastric siphonage for 3 or 4 daysafter operation, the removal of the tube depending upon the time at whichsatisfactory peristalsis was reestablished. The use of the tube beyond thisperiod was undesirable, for it might mask an intestinal obstruction and delayits recognition and correction. An accurate record of the daily intake andoutput was necessary during the period in which nasogastric suction was in use.
General measures-If morphine was indicated for pain, it was given insmall doses, preferably gr. 1/6 andnever more than gr. ?.
Patients were encouraged to get out of bed promptly if other wounds did notcontraindicate ambulation. If drainage had been instituted, ambulation usuallyhad to be delayed until the water-seal catheter was removed, but these patientswere encouraged to sit on the side of their beds.
The sulfonamides and penicillin were used according to the routine describedfor thoracic wounds (vol. I).
Vitamins B and C were given routinely in the postoperative period to improvethe nutritional status.
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The roentgenograms ordinarily taken in chest injuries 4 or 5days after operation were usually deferred until after the first week inthoracoabdominal wounds. Clinical signs provided a satisfactory guide tomanagement.
Drainage
The care of water-trap drainage in the postoperative periodrequired constant vigilance on the part of the surgeon and a thorough knowledgeof the method plus conscientious attention on the part of the nursing and otherstaff members of the forward hospital. Serious errors might result whenuntrained personnel were entrusted with this phase of the patient's care.
The catheter was connected with the water-seal bottle as soonas the patient was returned to the ward. If two tubes were used and penicillinhad been left in the pleural cavity, the posterolateral tube was kept clampedfor 3 to 4 hours, to give the penicillin time for bacteriostatic action. Thepatient was watched closely and the tube was unclamped immediately ifpneumothorax or hemothorax seemed to be developing.
The water-seal bottle was kept at least 18 inches below the most dependentpart of the pleura. The tube was clamped off whenever the bottle had to beemptied. It was the general practice to continue water-trap intercostal tubedrainage for 48 to 72 hours unless the tube became sealed off earlier; thissometimes occurred within 24 hours.
After the tube had been removed, and earlier if drainage had not beeninstituted, aspiration of blood and air from the chest was carried out asindicated. Daily aspirations were sometimes necessary. Often a pocket of air wasevident anteriorly, even when drainage had been instituted by lateral orposterolateral intercostal drainage. It was aspirated at once.
The proper removal of drains down to the liver was as important as theirinitial placement. They were gradually shortened, usually beginning on thefourth or fifth day. Manipulations had to be cautious and gentle. If the drainswere withdrawn too far and too fast, fluid collections were likely to becomepocketed in the hepatic region.
The amount of drainage through tubes placed down to the liver was generally,though not always, related to the amount of hepatic damage. The period ofdrainage was unpredictable, but it was seldom shorter than from 10 to 12 days,which meant that the final removal of drainage tubes was usually theresponsibility of the surgeon in the base hospital.
MANAGEMENT IN BASE HOSPITALS
Of the patients who survived to reach base hospitals after surgery forthoracoabdominal wounds, about half would have had involvement on the left sideand would have undergone, variously, splenectomy; repair of gastric lacerations;exteriorization of a segment of the colon, usually the splenic flexure
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or descending colon; nephrectomy in a small number of cases; or variouscombinations of these procedures.
Of the patients with right-sided injuries, the majority would have hadinjuries of the liver as the only intraperitoneal injury. The remaining patientswith injuries on this side would have had thoracotomy with inspection of theabdomen, repair of the diaphragm, and laparotomy to deal with injuriesinaccessible from the right hemithorax.
Except for the closure of traumatic wounds and of elective incisions in whichthe skin and subcutaneous tissues had been left open, the chief responsibilityof surgeons in base hospitals in respect to thoracoabdominal wounds was themanagement, and sometimes the closure, of colostomies and the management ofcomplications.
Management of Colostomies
The management of colostomies in thoracoabdominal injuries was theresponsibility of general surgeons in base hospitals. In many cases, perhapsmost cases, the patient had recovered entirely from his chest injuries longbefore the closure of his colostomy was undertaken. Many patients withthoracoabdominal injuries had to be evacuated to the Zone of Interior becausethe colostomy could not be closed within the permitted holding period of thetheater or because, for other reasons, closure could not be attempted overseas.
There was no standard surgical technique for the management of wounds of thecolon in the Mediterranean theater, but all the techniques employed were basedon three general principles (1):
1. Exteriorization of the wounded segment of bowel to prevent intraperitonealleakage at the suture line. The damaged exteriorized segment could be used asthe site of colostomy on appropriate indications.
2. Diversion of the fecal stream away from wounds of the distal or lowercolon and rectum. Colostomy was always performed for perforation of the rectumand was supplemented by adequate posterior drainage through the fascia propria.
3. Incomplete diversion of the fecal stream, which was a temporary measure,designed for purposes of decompression as well as to bring the bowel to thesurface, so that a diversional colostomy could be performed.
As might be expected, when so many different surgeons had operated on so manypatients under such widely different circumstances, with only principles toguide them, the colostomies that had to be closed represented every knowntechnique. Closure therefore had to be accomplished by a corresponding varietyof techniques. Both intraperitoneal and extraperitoneal methods were foundsatisfactory. Careful preoperative preparation was a criterion of success.
Techniques of the closure of colostomies and the management of complicationsassociated with them are presented in detail in the volume on general surgerydevoted to abdominal injuries (1).
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Complications
As might be expected in the circumstances of war, the records ofcomplications of wounds were always incomplete and were particularly fragmentaryin respect to the less severe and nonfatal types. Many postoperative processeswhich in civilian practice would be regarded as complications were so frequentin battle wounds that they came to be accepted as routine and were not made amatter of record.
These statements are all applicable to the 903 thoracoabdominal wounds caredfor by the 2d Auxiliary Surgical Group. In 529 instances, the records bear noindication that complications occurred, which naturally is incredible. There isonly one recorded case, for instance, of postoperative pulmonary edema. Thelargest numbers of complications were recorded for atelectasis, 21 cases;empyema, 19 cases, 2 of which where associated with bronchopleural fistula;subphrenic abscess, 15 cases; and pneumonia, 12 cases. Ten disruptions of theabdominal wound were recorded, in three instances with evisceration.
Postoperative complications were remarkably few, consideringthe character of the wounds, but individual surgical experiences often includedmore than these presumably total figures indicate. Maj. Thomas H. Burford, MC,for instance, in 98 lacerations of the liver treated at base hospitals,collected 14 subphrenic abscesses (fig. 38), 5 bile empyemas, and 6 intrahepaticabscesses (fig. 39).
Right-sided thoracoabdominal injuries gave rise to a higherpercentage of complications than left-sided injuries because of the almostuniversal involvement of the liver on this side. It was estimated thattransdiaphragmatic biliary fistulas, with bile empyema, developed in about 3percent of the lacerations of the liver in right-sided wounds. The incidence ofhepatic abscesses was put at about 1 percent.
Almost without exception, patients with left-sided injuries did well if theysurvived the first week. Complications arising within the abdomen weresignificantly less than on the right side, though an occasional left-sidedsubphrenic abscess required drainage.
Bile empyema-Bile empyema resulting from the intrapleural,transdiaphragmatic drainage of bile was always serious. The complication was notusually lethal, but it invariably showed a troublesome predilection towardchronicity, which was attributed to the presence of bile in the pleural cavity.
Attempts at decortication of the lung, with excision of the fistula and tightdiaphragmatic repair, failed consistently when they were undertaken as late as 6or 8 weeks after injury. At this stage, it seemed impossible to achieve completepulmonary remobilization and total pulmonary reexpansion. On the other hand,early surgical attack, within 3 or 4 weeks after injury, gave gratifying results(p. 130). An important phase of the operation was the provision of adequateextrapleural, extraperitoneal drainage for the bile leakage. This wasaccomplished by placing the rubber tissue drains exactly at the point of
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hepatic injury while the diaphragm was still open and bringing them outthrough a generous subcostal wound.
Subphrenic abscess-Subphrenic abscesses were almost universally of theanterior type and most frequently developed from an inadequately drainedtransdiaphragmatic abscess of the liver (fig. 40). They were treated by adequatedrainage, which occasionally necessitated resection of a segment of the tenthrib below the pleural reflection. Most patients showed satisfactory progresstoward healing of the underlying biliary fistula by the time they were evacuatedto the Zone of Interior. In one instance, a left-sided subphrenic abscessruptured through into the left lower lobe bronchus. Adequate drainage below thediaphragm resulted in prompt and complete cure.
In an occasional case, a bile empyema and a subphrenic abscess coexisted:
Case 1-This patient sustained apenetrating shell-fragment wound of the right chest on 14 April 1945.Exploratory thoracotomy on the same day revealed a penetrating wound of theright half of the diaphragm and a laceration of the liver. Subcostal drainagewas instituted, and the diaphragm was closed with interrupted cotton sutures.The immediate postoperative course was uneventful. The subcostal drains wereloosened on the fourth postoperative day and removed on the seventh day.
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FIGURE 39.-Thoracoabdominal wound requiringlater drainage of large intrahepatic abscess.
When the patient was received in the chest center at the 70thGeneral Hospital, Pistoia, Italy, the following day, there was considerablebile-stained fluid in the right chest. The fluid rapidly became purulent andshowed persistently large percentages of bile. Later, roentgenologic examinationrevealed a right subphrenic abscess (fig. 41A).
In preparation for surgery, the patient was given 1,500 cc. ofblood in 48 hours, which restored the hematocrit value to 40. He was also givenpenicillin systemically. Exploration on 28 April, 2 weeks after injury, revealeda large subphrenic abscess and an extensive bile empyema. The one-stageoperation performed consisted of drainage of the subphrenic abscess,decortication of the lung, excision of the fistula, and closure of the diaphragmwith interrupted silk sutures. Decortication was accomplished withoutdifficulty, and pulmonary reexpansion was prompt and complete. The fistulousopening in the diaphragm, at the site of the previous repair, was excised. Withthe diaphragm open, the cluster of rubber tissue drains that had previously beenplaced were carried down to the wound in the liver. The diaphragm was closed intwo layers, with interrupted sutures of fine silk. The chest was closed tightlyafter irrigation of the pleural cavity with physiologic salt solution and theintroduction of anterior and posterior intercostal catheters. Penicillin (25,000units) was instilled into the pleural cavity and left in situ for 6 hours.
The wound healed promptly (fig. 41B), and recovery wasuncomplicated and complete (fig. 41C).
Other complications-Bronchobiliary fistulas were infrequent. Onepatient with this complication died of unexplained, massive retroperitonealhemorrhage while he was being prepared for surgery.
Complications of left-sided thoracoabdominal wounds were sometimes bizarre.In one instance, a soldier with a previously unrecognized congenitaldiaphragmatic hernia received a chest wound. The colon was perforated, and whatamounted to a traumatic colostomy developed; 3 days after wounding,
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FIGURE 40.-Continued. C. Lateralroentgenogram showing abscess in characteristic anterior position.
feces were found pouring out through the broken-down thoracotomy wound.
Two patients were observed with gastropleural fistulas. In each instance, thegastric repair had broken down and had caused the breakdown of the diaphragmaticrepair. Both fistulas were difficult to close because the skin was so badlyexcoriated from irritating gastric secretions.
An extremely troublesome complication, which fortunately wasuncommon, was the so-called plastic type of peritonitis. Presumably, it wascaused by the slow leakage of bile into the general peritoneal cavity. Theplastic, nonpurulent exudate that resulted matted the loops of intestinetogether and gave rise to intermittent bouts of partial intestinal obstruction.Prompt decompression by the Wangensteen or Miller-Abbott technique was the usualtreatment. Operation was required only in an occasional case.
CASE HISTORIES
The following case histories are illustrative of various aspects ofthoracoabdominal wounds:
Case 2-Thissoldier was operated on in a field hospital, under endotracheal etheranesthesia, 3 hours after sustaining a severe perforating gunshot wound of theleft chest, with abdominal involvement. The chest was entered through aleft-sided thoracotomy; an 8-inch segment of the ninth rib was resected.
The chest cavity contained the entire stomach,which was tremendously dilated; a portion of the jejunum: the omentum; thetransverse colon with the splenic flexure; and the spleen. The stomach, jejunum,colon, and kidney were found to be intact. The badly lacerated spleen wasremoved. Insertion of a stomach tube reduced the stomach to 40 percent of itsoriginal size. The left gastroepiploic artery, which was torn near itstermination, was ligated. A tear in the lesser omentum was repaired. After theherniated
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organs were replaced in the peritoneal cavity, the diaphragmwas closed in two layers with interrupted silk sutures. The tip of the lowerlobe of the left lung, which was badly torn and bleeding, was resected, and thewound sutured with fine catgut on a swaged needle. After an intercostal catheterwas inserted, closure was effected with pericostal sutures and suture of themuscle layers. The patient was evacuated to a base hospital on the 12th day inexcellent condition.
Comment-This case historytypifies the multiple character of left thoracoabdominal injuries because of theclose proximity of the organs in the left upper quadrant of the abdomen to eachother. The history also demonstrates their ready accessibility through atransthoracic approach. When the diaphragm is opened, they actually rise intothe pleural cavity.
Case 3-This soldier sustained apenetrating shell-fragment wound of the tenth left interspace in the posterioraxillary line. The wound was explored at a forward hospital, which came undershellfire during the operation. Closure was therefore hurriedly effected aftersuture of the diaphragm. When the casualty was received at an evacuationhospital 24 hours later, his record contained a note from the forward surgeonthat he "thought a laparotomy should be done." The man was in greatpain, and his abdomen was considerably distended.
When the abdomen was opened through a left rectus incision,the peritoneal cavity contained fresh blood, but all viscera appeared intact.
Thirty-six hours after operation, the thoracotomy wound becamecrepitant and edematous, and a foul odor was noted. When the wound was explored,a typical clostridial myositis of the superficial muscles was found. The muscleswere already necrotic. Death occurred 12 hours later. Autopsy confirmed thediagnosis of clostridial myositis of the chest wall and also revealed aperforation of the splenic flexure of the colon.
Comment-Theinjury of the retroperitoneal portion of the splenic flexure was not identifiedat laparotomy in this case. It would probably have been found, and could haveeasily been handled, had a transthoracic approach been employed.
Case 4-This soldier was admittedto a field hospital with a rigid abdomen shortly after sustaining a penetratingwound of the right lower chest. Thoracotomy was performed, with resection of thetenth rib, and a laceration of the lower lobe of the right lung was sutured. Thediaphragm was perforated and the liver lacerated; the missile lay in the tear.Inspection of the duodenum, hepatic flexure, and kidney revealed no furtherdamage. The wound in the liver was drained subdiaphragmatically before thediaphragm was closed with two layers of interrupted silk sutures. The patientwas in good condition when he was evacuated on the sixth postoperative day.
Comment-Thiscase is one of 17 right-sided thoracoabdominal lesions, 12 of which were handledsatisfactorily by the transthoracic approach.
Case 5-This soldier was receivedin a field hospital with a blood pressure of 90/50 mm. Hg and a pulse of 140,after having sustained a gunshot wound of the left chest and abdomen. He hadreceived 500 cc. of plasma before admission. No respiratory difficulty wasapparent, and breath sounds were present, though somewhat diminished on theleft. The abdomen was spastic and moderately tender. He complained of suprapubicpain.
The wound of entrance, which was 1.5 cm. in diameter, was inthe seventh interspace anteriorly, 2 inches from the midline. The ragged woundof exit, 7.5 cm. in diameter, was in the ninth interspace, just medial to theposterior axillary line. Aspiration of the left chest produced about 30 cc. ofblood and a small amount of air.
After a plasma transfusion of 500 cc. had been given, a bloodtransfusion was started and ether-oxygen anesthesia induced. A subcostallaparotomy incision was made. Exploration revealed approximately 800 cc. ofblood, mixed with gastric contents, in the peritoneal cavity. The stomach wasgreatly distended. The lesser peritoneal cavity was not involved. The spleen waslacerated, and a perforating wound was found in the cardia.
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The wounds of entrance and exit in the cardia were closed intwo layers with chromic catgut by the inverting technique. When the spleen wasdelivered, a 6-cm. sucking laceration of the posterior portion of the diaphragmbecame evident. It was closed with difficulty after the spleen had been removed.Another nonsucking laceration of the diaphragm was easily repaired. The abdomenwas closed in layers.
The patient's condition was not satisfactoryat any time during the 90-minute procedure, and he died while the skin sutureswere being inserted. At no time did the blood pressure rise above 90/60 mm. Hg,in spite of the continuous administration of blood, and there was a gradualdecrease in pressure during the last 30 minutes of the operation.
Comment-The first error made inthis case was failure to have an endotracheal tube in place before the abdomenwas opened. The large sucking perforation of the diaphragm was not apparentuntil the lacerated spleen was delivered and its tamponade effect on thediaphragm was lost. Except for the application of an ineffective gauze pack, thediaphragmatic laceration had to be ignored until splenectomy was completed. Mostof the operating time was spent in accomplishing a difficult diaphragmaticclosure. The sudden collapse of the left lung was more than an already shockedpatient could tolerate. Had endotracheal anesthesia been used, with facilitiesfor maintaining positive intrapulmonic pressure during operation, pulmonarycollapse would not have occurred. The major error of management was not toemploy the transthoracic approach, through which the entire procedure could havebeen carried out with a great reduction in risk.
EXPERIENCE OF THE 2D AUXILIARY SURGICAL GROUP
The World War II experience of the 2d Auxiliary SurgicalGroup in the Mediterranean theater included 903 thoracoabdominal wounds, 247 ofwhich were fatal. These wounds were encountered chiefly during 1944 and 1945,but 68 wounds, 25 of which were fatal, were observed in 1943. During the same1943-45 period, the teams of this group encountered 1,364 thoracic wounds.Thoracoabdominal wounds thus accounted for almost 40 percent of all wounds ofthe chest.
Certain data concerning these 903 thoracoabdominal woundshave been cited in the preceding pages. Additional data, and certain conclusionswhich can be drawn from them, follow.
General Data
The great majority of these casualties were U.S. Armyinfantrymen, with Wehrmacht prisoners of war accounting for the next largestgroup. The figures also cover some British and French soldiers and a fewcivilian casualties.
The age factor was of little significance, as the great majority of thepatients were young, healthy males. In the 762 cases in which the age wasrecorded, there were only 4 patients over 40 years of age. There were 190casualties 20 years of age and under; 297 in the 21- to 25-year group; 176 inthe 26- to 30-year group; and 95 in the 31- to 40-year group.
Artillery and mortar fire was responsible for 590 of the 903wounds, and rifle, machinegun, and pistol fire for 245. The remaining woundswere caused by bombs, mines, and grenade fragments.
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In 837 cases, the missiles entered the abdomen through the thorax. In theother 66 cases, they entered the abdomen and then penetrated the diaphragm. In418 cases, the wounds were on the right side and in 419 on the left side. In 20cases in which both diaphragms were perforated, the wound of entry was on theright in 7 and on the left in 13. No information is available on this point inthe remaining 46 cases.
Timelag
There was no record of the timelag in 49 cases, 11 of whichwere fatal. In the 854 cases in which information on this point is available, itvaried from less than an hour to more than 30 hours (table 8).
At first glance, the high mortality rate in the group in which the timelagwas shortest might seem to invalidate the concept that the earlier a casualtywith a thoracoabdominal wound could be operated on, the better were his chances.It does not. The high rate reflects the fact that the nearer the frontline afield hospital is set up, the more casualties will be brought to it who will diethere rather than on the battlefield. This was particularly true on the Anziobeachhead, when both field and evacuation hospitals were very far forwardbecause the sector occupied was too small for them to be placed farther back. Onthe beachhead, one patient died of an injury of the portal vein, and five diedof injuries of the vena cava, in hospitals. If the evacuation distance had beenlonger, they would not have reached them alive.
There were 8 deaths in the 34 casualties who came to operation 30 hours ormore after wounding. Two had wounds of the liver, three wounds of the spleen,and one a wound of the kidney. In the two remaining cases, the missilepenetrated the peritoneal cavity without damage to any viscera.
Surgical Approach
The transthoracic approach was used in 448 of these 903thoracoabdominal injuries (table 9). In 86 patients in this group, surgery waslimited to thoracotomy, exploration, removal of foreign bodies, or simpleretroperitoneal
TABLE 8.- Casefatality rate according to timelag in 854 thoracoabdominal injuries1
Timelag | Cases | Deaths | Percent |
To 6 hours | 221 | 64 | 28.9 |
To 12 hours | 400 | 96 | 24.0 |
To 18 hours | 122 | 39 | 31.9 |
To 24 hours | 54 | 20 | 37.0 |
To 30 hours | 23 | 9 | 39.1 |
Over 30 hours | 34 | 8 | 23.5 |
| 854 | 236 | 27.6 |
1In 49 of the 903 cases in this series, there was no record of thetimelag. There were 11 fatalities in this group.
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TABLE 9.-Case fatality rate according to surgical procedurein 903 thoracoabdominal wounds
| Procedures | Cases | Deaths | Percent |
| Transdiaphragmatic laparotomy | 448 | 91 | 20.3 |
| Laparotomy | 202 | 77 | 38.1 |
| Thoracotomy and laparotomy | 144 | 36 | 25.0 |
| Laparotomy and thoracotomy | 74 | 26 | 35.1 |
| Transdiaphragmatic laparotomy and laparotomy | 20 | 7 | 35.0 |
| Thoracolaparotomy1 | 6 | 3 | 50.0 |
| No surgery | 3 | 1 | 33.3 |
| Death during surgery | 6 | 6 | 100.0 |
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1 In this technique, the thoracic incision was extended onto theabdomen over the chondral arch.
drainage. In the remaining 362 cases, the entire abdominalprocedure, which involved surgery on 31 different combinations of organs, wasperformed through the chest incision.
In 202 other cases, the entire procedure was abdominal.
A comparison of the case fatality rates in the injurieshandled by the transthoracic approach and those handled by the abdominalapproach, 20.3 percent versus 38.1 percent, might suggest the far greatersuperiority of the transthoracic approach. These data should not be soconstrued. The results in the individual case depended upon the magnitude of theabdominal and thoracic problems (table 7). Generally speaking, however, theresults were better if the thoracotomy approach was used for perforating woundsin the upper zone of the left diaphragm or penetrating wounds in whichroentgenograms showed that the missile lay within the area of the dome of thediaphragm.
Factors of Mortality
General considerations-The gross case fatality rate for the 903thoracoabdominal injuries cared for by surgeons of the 2d Auxiliary SurgicalGroup was 27.4 percent (247 deaths). These figures are for first priorityhospitals, in which the postoperative stay, though it varied from a few days toas long as 18 days, was usually from 7 to 10 days.
Conditions in theaters of operations made it extremelydifficult to determine the end results of forward surgery. Reports fromevacuation and base hospitals were all to the effect that patients operated onin field hospitals did well after they reached hospitals farther to the rear. Itis probable, therefore, that a more complete followup would not have materiallyaltered the case fatality rates in forward hospitals.
There was an interesting and probably significant decrease in the casefatality rates of thoracoabdominal injuries as time passed:
In 1943, there were 25 deaths in 68 cases, 36.8 percent.
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Between January and June 1944, there were 84 deaths in 243 cases, 34.6percent.
Between July and December 1944, there were 98 deaths in 392 cases, 25.0percent.
Between January and the first week in May 1945, when the war ended, therewere 40 deaths in 200 cases, 20.0 percent.
The decreasing case fatality rate in the latter half of 1944 and 1945coincided with the introduction of penicillin. Antibiotic therapy undoubtedlyplayed a part in the improvement. Another explanation of the improvement isapplicable to the first half of 1944, the establishment of a theater blood bankand the increasingly liberal use of whole blood.
Surgeons in the theater, however, believed that theimprovement in the case fatality rate could reasonably be assumed to be areflection of their greater knowledge and experience in dealing with thesewounds; a greater appreciation of the implications of the thoracic component andthe complications which could arise from it; a greater facility on the part ofindividual surgeons and anesthesiologists (the so-called learning curve); and akeener appreciation of, and greater attention to, details of resuscitation andof preoperative and postoperative care.
Effect of thoracic and abdominal components of wound-When themediastinum was injured, the case fatality rate was 54 percent. Otherwise, itwas impossible to discover, from a study of these cases, exactly what effect thechest component of the wound had, beyond the far-reaching influence ofcardiorespiratory disturbances that were not promptly corrected.
With these exceptions, there was no doubt that the most lethal part of thewound was the abdominal component. The precise organs injured and the number ofinjuries below the diaphragm were reflected in the mortality rates (table 7).Wounds of hollow viscera carried a much higher rate than wounds of solidviscera, though an occasional fatality was caused by an overlooked wound of asolid viscus.
The number of organs injured also played an important role.Wounds of five or more viscera were universally fatal. These subjects arediscussed in more detail in the volume in this series devoted to abdominalinjuries (1).
Anatomic considerations.-The side on which the injury waslocated played a part in the mortality rate, for anatomic reasons. The figuresare as follows:
Perforations of the right diaphragm, 435, with 103 deaths(23.6 percent).
Perforations of the left diaphragm, 448, with 136 deaths(30.8 percent).
Bilateral perforations, 20, with 8 deaths (40 percent).
Anatomic reasons are also connected with the case fatalityrates for herniation of the abdominal viscera into the chest cavity. In the 5instances of evisceration into the right pleural cavity there were 2 deaths,against 13 deaths in 35 herniations through the left diaphragm.
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Time of death-The day of death was recorded in 234 of the 247fatalities:
1. There were 154 fatalities in the first 48 hours, including 49 deaths onthe operating table (40 from shock, 4 from hemorrhage, 3 from atelectasis, and 1each from cardiac tamponade and vagovagal reflex during bronchoscopy). All but13 of the 130 deaths from shock occurred within this period. The case fatalityrate could be directly related to the degree of shock in which the casualtieswere received:
No signs of shock, 145 patients, 8 deaths (5.5 percent).
Mild shock, 75 patients, 10 deaths (13.0 percent).
Moderate shock, 174 patients, 31 deaths (17.5 percent).
Severe shock, 275 patients, 164 deaths (59.6 percent).
There is no record of the degree of shock in the remaining 234 cases, inwhich there were 34 deaths (14.5 percent).
In addition to shock, chiefly due to blood loss, deaths early in thepostoperative period were caused by uncorrected (occasionally irreversible)disturbances of cardiorespiratory physiology, overwhelming contamination andinfection of the peritoneal and pleural cavities and retroperitoneal space, andmassive tissue destruction.
2. There were 28 deaths between the third and fifth days. Of these, 13 weredue to renal failure, as evidenced by oliguria and anuria (vol. I); peritonitisand pneumonia were the next most frequent causes.
The 22 deaths from peritonitis occurred between the day of operation and the10th postoperative day. The fact that 17 had occurred by the end of the thirdday is evidence of the catastrophic effect of the so-called contamination typeof peritoneal infection, with sudden, massive soiling of the cavity.
3. There were 10 deaths from pulmonary embolism, all between the day ofoperation and the 11th postoperative day; 6 occurred within the first 72 hours.
Other occasional causes of death included missed perforations of hollowviscera, mismatched blood, blast injury, mediastinitis, empyema, fat embolism,pressure pneumothorax with bronchopleural fistula, liver death, clostridialmyositis, disruption of the diaphragm, morphinism, and meningitis.
Associated wounds-Wounds in other parts of the body accounted for someof the 247 deaths in this series or played an important part in the fatality. Ofthe 385 associated wounds, 161 were classified as mild, and the 34 deaths inthis group (21.1 percent) can probably be attributed entirely to thethoracoabdominal wounds. The same reasoning perhaps holds for the majority ofthe 129 associated injuries of moderate severity, in which there were 33 deaths(25.6 percent). In the 95 associated injuries classified as severe, there were36 deaths (37.9 percent). There can be no doubt that in many instances in thisgroup the associated injuries played an important role, if not the major role,in the fatality. Among these 95 severe associated wounds there were:
26 cord injuries, with 16 deaths.
7 brain injuries, with 1 death.
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15 fractures of the femur, with 4 deaths.
9 traumatic amputations, with 3 deaths.
8 other abdominal (not thoracoabdominal) wounds, with 4 deaths.
The influence of severe associated wounds is evident in a casualty cared forby Maj. (later Lt. Col.) Reeve H. Betts, MC. This was the only casualty with athoracoabdominal wound to die before operation in the 29 such injuries handledby his team. This soldier had a right traumatic thoracotomy, a leftthoracoabdominal wound, a traumatic amputation of the right arm, and a severewound of the right thigh. In spite of vigorous attempts at resuscitation,including the administration of 500 cc. of plasma and 3,500 cc. of blood, hisblood pressure was never obtainable, and he died 5 hours after wounding.
It might be added that associated wounds, in addition to thepart they played in the case fatality rate of thoracoabdominal wounds, alsoplayed a major role in their morbidity.4
References
1. Medical Department, United States Army. Surgery in World War II. GeneralSurgery. Volume II. Washington: U.S. Government Printing Office, 1955.
2. Snyder, Howard E.: The Consultant in Surgery, Fifth U.S.Army. In Medical Department, United States Army. Surgery in World War II.Activities of Surgical Consultants. Volume I. Washington: U.S. GovernmentPrinting Office, 1962, pp. 333-464.
4 The reader is referred to chapterXI (p. 441) for long-term followupstudies on casualties with thoracoabdominal wounds.
